Douglas Kennedy, Consultant Maxillofacial Surgeon, considers the content of the RCSEd's Ballistic Facial Injury study day in November 2010
Readers of Surgeons’ News will not be surprised to know that the military uses sophisticated medical data collection methods. Data is collected regarding patterns of injury in wounded personnel. The analysis of the data allows changes in patterns to be recognised and changes can then be made to equipment and medical training. For example, protective equipment can be made even more effective, or the training of deploying surgeons can be focused on management of the most commonly seen injuries.
"Currently the military has an effective pre-deployment training course that all surgeons attend to hone their skills in these areas"
A good example of changes in the pattern of injury over time has been an increase in the prevalence of facial trauma in conflict. Injury to the head, face and neck was found in around 16% of cases from twentieth century conflict, and this figure now approximates 30%. The reason for this increase may be related to the effectiveness of body armour, now routinely worn, in protecting other sites.
The primary care of ballistic facial injury relies heavily on effective management of a potentially compromised airway and possible significant bleeding. Clearly, associated head injuries and eye injuries must also be diagnosed and treated. Currently the military has an effective pre-deployment training course that all surgeons attend to hone their skills in these areas.
There are few British facial surgeons that regularly treat ballistic trauma in their practice. Most military surgeons are employed in NHS hospitals while not actively deployed in conflict areas. The Royal College of Surgeons of Edinburgh recently hosted a study day specifically on the topic of Ballistic Facial Injury. Attended by military and civilian surgeons with an interest in trauma care, the day explored the clinical experience of surgeons who have been deployed overseas, and the work of surgeons who have treated military patients on their return to the UK. Although not common, there are some NHS hospitals that have experience in treating gunshot and blast wounds in a civilian environment. Speakers from these hospitals discussed lessons learned in their management.
Modern facial reconstructive surgeons have a wide and effective armamentarium in terms of internal fixation equipment and tissue transfer techniques. The role and timing of using these techniques in ballistic trauma is not fully established. Direct fixation techniques that involve wide periosteal stripping, reducing blood supply, are commonly used in civilian trauma care but may not hold all the same advantages in ballistic trauma.
It is commonplace in major head and neck cancer surgery to transfer tissue from a distant donor site. Bone and soft tissue can be transferred to defects and have a blood supply reconnected by microvascular surgery. The use and timings of this type of complex reconstruction is a topic of debate, as ballistic trauma defects are clearly different from those created by ablative cancer surgery. Ballistic injuries, by their nature, are grossly contaminated and vitality of tissues is compromised. Seldom used fixation techniques such as intermaxillary fixation and external fixators may allow the required stability of fractures while wounds are cleaned and vitality can be established. There is recognition that keeping things simple may well be the most effective route of treatment.
At the study day, experienced ophthalmic surgeons and neurosurgeons led discussions regarding associated eye and craniofacial trauma. Fractures that extend upwards into the skull base allow the possibility of ascending infection. There are surgical techniques used to decrease the chances of this infection occurring and their use in ballistic trauma will be discussed. Devastating eye trauma may cause visual loss, but the damaged site still needs to be appropriately treated. Students, nurses and doctors from all specialities involved in facial trauma attended the event, as well as the related event on Injury of Conflict, held the following day. They had a valuable educational experience and I hope their discussion of difficult cases will eventually benefit injured soldiers or civilian victims.
Douglas Kennedy
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