The variety of gunshot wounds and injuries requires a purely individual approach to their treatment, depending on the nature of the destruction of tissues and organs, the severity of the injury, concomitant complications, etc. Experience in the treatment of gunshot injuries allows recommending two different approaches to surgical treatment: all injuries and injuries inflicted with with a small force of a wounding weapon, they can be treated according to the method of treating peacetime injuries (non-gunshot), while gunshot injuries inflicted with an “explosive” effect require active irurgicheskogo interfering with a thorough revision of the wound channel along its entire length in the area of soft tissue injuries, and facial skeleton and related areas.
Wounds and injuries of the maxillofacial region
A wound is a mechanical damage to tissues with a violation of the integrity of the integument (skin, mucous membrane, sclera, cornea, etc.), it belongs to the group of open injuries accompanied by pain, bleeding and gaping. Wound-a set of damage to tissues and organs along the entire wound channel. Depending on the circumstances of the wound, surgical wounds (postoperative, for example, after tooth extraction), random and received in battle, are distinguished. According to the application mechanism and the nature of the wounding weapon, wounds are divided into cut, chopped, bruised, torn, bitten, mixed (like stab-chopped, torn-bruised, etc.) and gunshot.
The course of the wound process is a complex biological phenomenon that has a strictly defined cyclicity and ends with wound healing. The healing process can proceed by primary intention, i.e., with the formation of a young scar on the 6-7th day of the wound, or secondary tension (due to rejection of necrotic tissue, the development of infection, etc.), followed by filling the wound with granulation tissue, scarring and epithelialization of the wound. In a different way, wound healing occurs when combined damage by chemical agents, electric current, radioactive radiation, as well as in gunshot wounds.
The clinical picture. The main signs of a wound: pain, bleeding, gaping, dysfunction. The intensity of the pain depends on the type of wounding weapon, the degree of tissue destruction, damage to nerves and nerve plexuses, foreign body pressure, displacement of bone fragments, correct dressing and means of immobilization, type of transportation of the victim, the nature of the invading infection, etc. Bleeding occurs in each wound, but its intensity is due to a number of reasons. Gaping wounds depends on the extent of the gap, the size of a flaw tissue gravity hanging destroyed parts (flaps) face, broken facial bones, skin elasticity, reduce chewing and mimic muscles of the face, the displacement of tissue blow wounding weapons, development of inflammatory edema, and others. The functional disorders in facial injuries are often observed. These include disturbances in breathing, speech, the act of chewing and swallowing food, salivation, disorders of innervation and the psyche. According to the size of the wound is divided into minor (small) and with a large area of damage. In shape, they can be linear, perforated, patchwork and with a defect (defect, loss) of tissues. The number of wounds is divided into single and multiple. In relation to the oral cavity, nose, skull, neck – penetrating and non-penetrating.
Anatomically distinguish soft tissue wounds, wounds with bone damage (open and closed fractures). The severity of the damage is lungs, moderate, severe and terminal (fatal) injuries. In case of injuries of the maxillofacial region, penetrating into the oral cavity, adnexal nasal cavity, pharynx and larynx, they are considered as infected. The clinical course of infected wounds has features and is fraught with concomitant complications. The spread of infection with facial injuries manifests itself particularly rapidly in wounds with a narrow wound channel penetrating the oral cavity. It differs in a characteristic purulent-necrotic process, which makes the tissues acquire a gray-green color and produce a fetid odor. In wounds that penetrate the sublingual, submental and submandibular regions (especially in young people), the spread of infection is characterized by extensive dense inflammatory edema, pain, high fever, often with shortness of breath (stenotic asphyxia) and swallowing. In this case, the lymph nodes are enlarged, the development of an abscess and phlegmon is possible . With exhaustion and hypovitaminosis in a wounded person, the temperature can be subfebrile, which sometimes makes it difficult to recognize developing sepsis, mediastinitis, aspiration pneumonia, etc. There may be outbreaks of reinfection due to the development of traumatic (gunshot) osteomyelitis of the jaws, which are especially dangerous due to secondary bleeding.
Reinfections can be associated with the presence of foreign bodies in the wound, as well as concurrent diseases (diabetes, syphilis, tuberculosis, blood diseases, vitamin deficiency, etc.). The course of the wound process can be disrupted by the introduction of a specific infection into the wound (rabies, diphtheria, tetanus, erysipelas, etc.). Treatment. The main method of treating injuries of the maxillofacial region is the surgical treatment of wounds. It should be carried out taking into account the time elapsed after the injury. Early primary surgical treatment is carried out during the first 24 hours, it should be final in the nature and extent of the intervention. Delayed treatment is carried out after 24-48 hours, later – after 48 hours after injury. The conditions under which the primary suture can be applied to the wound must be strictly observed: during surgical treatment on the 1st day; in the presence of antibiotic therapy before and after treatment; stay of the wounded in a medical institution before removal of sutures. According to the timing of application, a delayed suture is distinguished , until granulation appears in the wound (day 4-5); early secondary suture in the presence of granulations in the wound and complete rejection of necrotic tissue; late secondary suture – with the development of scar tissue.
Further, according to indications, plastic closure of wound defects with various transplants is carried out.
Surgical treatment of a gunshot wound consists of several stages:
1. The wound is washed with an aqueous solution of furatsilina 1: 5000 or 1:10 000 and carefully removed foreign bodies, blood clots, fragments of bones and teeth. Excised carefully and economically crush -rvanye skin edges, whereupon a second wash solution or process furatsilina 2-3% hydrogen peroxide.
2. The wound is revised along the wound canal, in gaps and pockets, removing blood clots, foreign bodies, freely lying fragments of bones and teeth. Fragments of bones less than 2 cm in size, even if they are associated with soft tissues, are also recommended to be removed. The sharp edges of the bones smooth out. All crushed and non-viable tissues are economically cut off, preserving everything as much as possible for the subsequent restoration of the anatomy and function of the face. For wounds with an “explosive” effect, all wounds, even the smallest ones, must be thoroughly inspected to remove fragments of bones and teeth (especially wounds of the soft palate, pharynx, bottom of the mouth and tongue). In case of injuries of the upper jaw with an “explosive” effect, the maxillary sinuses, nasal passages and ethmoid labyrinth are revised, while all bone fragments and foreign bodies are removed and provide a reliable outflow into the nasal passages or into the oral cavity. In case of damage to the zygomatic bone and arch, free bone fragments are also removed, bite and smooth sharp edges, and then the fragments are adjusted. In case of damage to the walls of the orbit and eyes, consultation with an ophthalmologist and a neurosurgeon is necessary. Carrying out an audit of the nasal passages, after removing bone fragments and foreign bodies, the opener, sinks are carefully adjusted and the patency of both nasal passages is checked, after which PVC pipes or rubber tubes with a diameter of about 8 mm are inserted to the choan. In case of injuries of the lower jaw with an “explosive” effect, the bone itself, soft tissues in the hyoid area, the bottom of the oral cavity and adjacent areas of the neck are revised. Injury of the lower jaw in the region of the branch and head of the lower jaw can be accompanied by a rupture of the external auditory canal. In such cases, the auditory canal is audited, the destroyed tissue is put back in place, and then an elastic tube is carefully inserted into the entire passage to prevent obstructive scars. Assisting with mechanical injuries of the jaws of peacetime, the doctor has clear guidelines about the indications for treatment or tooth extraction. However, with gunshot injuries, especially with an “explosive” effect, with crushing of the jaws and teeth, the presence of mobile fragments, it is impossible to remove the teeth and roots of damaged teeth. Sometimes you have to leave teeth on the fracture line in those cases when they turn out to be the only reference points for fixing future prostheses. When revising blind wounds, it is necessary to use all the possibilities to remove a stuck wounding projectile, since in a fresh wound it is easier to do this during the initial treatment. In addition, such a measure will avoid possible complications ( arrosive bleeding, infection, etc.). However, one cannot always strive to remove a bullet or a fragment, since this operation is often difficult and impossible even in the presence of x-rays. After the audit is completed, the wound is treated with hydrogen peroxide, solutions of antibiotics or antiseptics, tools are changed.
3. Bone fragments are repositioned and fixed, choosing the most rational way to fix the fragments, taking into account the nature and location of bone fractures, the condition of the victim, his age and the presence of concomitant complications. The chosen fixation method should not lead to additional injury and provide active movement of the jaws and food intake. Orthopedic treatment is carried out taking into account biological, mechanical and prognostic factors. Surgical (operational) methods for fixation of fractures are indicated in those cases when it is not possible to reliably fix jaw fragments using conservative methods .
4. Sutures are applied to the mucous membrane and organs of the oral cavity. First of all, you need to strive to isolate the oral cavity from external wounds, especially penetrating into the hyoid, submandibular and submental region. Fx l and there are flaws in the mucous membrane, they resort to mobilizing it from neighboring areas, for example, from the geca , the bottom of the oral cavity and even from the hard palate. If the wound communicates with the oral cavity, maxillary sinus or with the nasal cavity, then resort to the same methods of closure with the mobilization of the mucous membrane. At the same time, stitches are placed on the flaps of the pharynx, soft and hard palate, and on the wounds of the tongue.
5. Suture the wounds of the soft tissues, taking into account the cosmetic and functional features of the face. The timing and amount of subsequent treatment of the patient depends on the correct suturing. In this case, the localization and nature of the wound, the timing of the patient’s admission are taken into account. The main ones are the degree of destruction and the presence of flaws in the facial tissues. With linear ruptures without crushing the edges of the flaps, especially in the nose, lips, eyelids, auricles, blind cosmetic sutures are applied. In case of injuries with an “explosive” effect, an extensive zone of tissue destruction, irregularly shaped rags, smashed and uneven edges, and tissue defects, wire-wound plate seams (guides, unloading, bringing together, purse-string, fixed at a distance and deaf) are imposed. In some cases, it is possible to close the tissue defect with the help of a plate seam (converging) with the subsequent application of a blind seam. If the defects in the facial tissues are extensive and the edges of the wound cannot be brought together, then the wound is sheathed along the entire edge of the flaw, that is, a blind suture is connected that connects the edges of the skin with the oral mucosa.
6. Large rags of soft tissues of the face, which due to gravity can be displaced, tearing and interfering with the restoration of the function of eating, speaking, breathing, are kept by purse-string plate sutures fixed at a distance to the facial bones or upper jaw.Such sutures have to be used for ruptures of the face, chin, submandibular and submental areas, the bottom of the mouth and neck, especially if the hyoid bone, tongue and larynx are pulled down and back not only due to its severity, but also due to contraction of the neck muscles. You can hold soft tissue flaps with long strips of adhesive tape. The flaps are additionally fixed with a correctly made dressing and the application of a transport head bandage with a rigid chin sling. In some cases, individual organs of the face, most often the back of the nose, less often the auricle and lips, and sometimes the tongue, have to be held by pelots made of aluminum wire, thermoplastic mass, quick-hardening plastic, etc. In some cases, a “cradle” type pelot should be made for temporary support and retention of the swollen tongue increased in size with defects of the lower jaw. Thus, with severe and extensive facial injuries, it is necessary to combine the methods of fixation purely individually for each wounded.
7. At the last stage of treatment, apply a bandage and correctly bandage the wounded. A well-applied dressing not only protects wounds, but also is an additional means of immobilizing damaged soft tissues and jaws. In this regard, the best is a transport headband with a rigid sling on rubber (elastic) traction. These rubber bands can hold bandages, pelots , adjust tension, etc. When applying bandages, one must take into account the nature of the injury, the time from the moment of injury, the features of care and nutrition, as well as transportation conditions and time of year. In all cases, surgical treatment is supplemented by the widespread use of drug, desensitizing, restorative therapy, a high-calorie diet rich in vitamins.
Deprive a simple face
Etiology and pathogenesis of lichen simple face
The causative agent of streptococcus. It occurs in children as well as in adults working outdoors. It occurs among organized groups of children in the spring and can often be endemic.
Clinic depriving a simple face
In open areas of the skin (face, hands), rounded pink spots appear, covered with small white or grayish-white scales. The spots have a clear scalloped shape, increasing in size due to peripheral growth and fusion. Subjectively mild itching, a feeling of tightening of the skin. Sluggish course and a tendency to relapse. After cure, a temporary depigmented spot remains. May be combined with streptococcal impetigo.
Differential diagnosis of simple face deprivation
Chronic trichophytosis of smooth skin. On the extensor surface of the elbow and knee joints, legs, buttocks, less often on the face, body, irregular pinkish-cyanotic spots with fuzzy borders and peeling on the surface appear. The process on the skin can be combined with simultaneous damage to the nails and scalp. Often accompanied by acrocyanosis and erythrocyanosis of the extremities. As a rule, in women, a dysfunction of the endocrine glands is detected , especially the genital. The course is chronic (many years). In a laboratory study, Trichophyton tonsurans is detected . Toxoderma . A history of taking medications and poor quality food. A sudden onset and an acute clinical course, a bright color of spotted rashes, peeling, a tendency to peripheral growth and fusion are characteristic. The rash is localized in the folds of the skin (axillary, ulnar). Subjectively soreness, burning, itching. Regression occurs quickly, on average 7-10 days after the onset of the disease.
Treatment for simple face deprivation
In the chronic course, antibiotics, immunoprotectors , biogenic stimulants, vitamins, general ultraviolet radiation. Topically disinfecting solutions, ointments and creams with antibiotics.