RESUMEN
INTRODUCTION: The evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons. METHOD: A systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management. RESULTS: Head, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair. CONCLUSIONS: The identification of those skill sets required for deployment is in keeping with the General Medical Council's current drive towards credentialing consultants, by which a consultant surgeon's capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.
Asunto(s)
Competencia Clínica , Traumatismos Craneocerebrales/cirugía , Medicina Militar , Personal Militar , Traumatismos del Cuello/cirugía , Traumatología , Consenso , Traumatismos Faciales/cirugía , Humanos , Reino UnidoRESUMEN
VIRTUS is the first United Kingdom (UK) military personal armour system to provide components that are capable of protecting the whole face from low velocity ballistic projectiles. Protection is modular, using a helmet worn with ballistic eyewear, a visor, and a mandibular guard. When all four components are worn together the face is completely covered, but the heat, discomfort, and weight may not be optimal in all types of combat. We organized a Delphi consensus group analysis with 29 military consultant surgeons from the UK, United States, Canada, Australia, and New Zealand to identify a potential hierarchy of functional facial units in order of importance that require protection. We identified the causes of those facial injuries that are hardest to reconstruct, and the most effective combinations of facial protection. Protection is required from both penetrating projectiles and burns. There was strong consensus that blunt injury to the facial skeleton was currently not a military priority. Functional units that should be prioritised are eyes and eyelids, followed consecutively by the nose, lips, and ears. Twenty-nine respondents felt that the visor was more important than the mandibular guard if only one piece was to be worn. Essential cover of the brain and eyes is achieved from all directions using a combination of helmet and visor. Nasal cover currently requires the mandibular guard unless the visor can be modified to cover it as well. Any such prototype would need extensive ergonomics and assessment of integration, as any changes would have to be acceptable to the people who wear them in the long term.
Asunto(s)
Cara , Traumatismos Faciales/prevención & control , Dispositivos de Protección de la Cabeza , Personal Militar , Heridas Relacionadas con la Guerra/prevención & control , Heridas por Arma de Fuego/prevención & control , Diseño de Equipo , Balística Forense , Humanos , Encuestas y CuestionariosAsunto(s)
Medicina Militar/estadística & datos numéricos , Boca/lesiones , Examen Físico/estadística & datos numéricos , Índices de Gravedad del Trauma , Heridas y Lesiones/diagnóstico , Humanos , Unidades de Cuidados Intensivos/normas , Medicina Militar/normas , Personal Militar , Examen Físico/normas , GuerraRESUMEN
UK service personnel sustaining maxillofacial wounds in Afghanistan are stabilised in a field hospital prior to evacuation for definitive treatment at the Royal Centre for Defence Medicine (RCDM). Descriptive injury data were gathered from the Joint Theatre Trauma Registry (JTTR) between 1 January 2008 and 31 December 2009 and matched to hospital clinical records. The mean Abbreviated Injury Severity (AIS) scores in service personnel sustaining maxillofacial wounds alone were compared with those with injuries to all body areas. Maxillofacial wounds were present in 21% of British servicemen sustaining battle injuries, but 30% of all evacuations despite the similar mean AIS of each group. This probably reflects the complex care these injuries often require that is not possible in the field. In the field hospital, maxillofacial wounds were predominantly debrided and definitive repair was deferred until evacuated to RCDM. AIS codes are an excellent predictor of mortality from face and eye wounds but they reflect morbidity poorly. The authors propose that instead of a single AIS code, each military face and eye injury should be ascribed a second separate Occulo-Facial Functional and Aesthetic (OFFA) outcome score that more accurately predicts the aesthetic and functional parameters of these wounds.
Asunto(s)
Campaña Afgana 2001- , Traumatismos Maxilofaciales/epidemiología , Personal Militar , Escala Resumida de Traumatismos , Traumatismos por Explosión/epidemiología , Desbridamiento/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Estética , Explosiones/estadística & datos numéricos , Traumatismos Faciales/epidemiología , Hospitales Militares/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Humanos , Laceraciones/epidemiología , Fracturas Mandibulares/epidemiología , Fracturas Maxilares/epidemiología , Traumatismos Maxilofaciales/cirugía , Personal Militar/estadística & datos numéricos , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Sistema de Registros , Fracturas Craneales/epidemiología , Traqueostomía/estadística & datos numéricos , Resultado del Tratamiento , Reino Unido/epidemiologíaRESUMEN
Our aim was to assess oral and maxillofacial operating theatre activity at the NATO Multinational Medical Unit at Kandahar Airfield (MMU KAF). We made a retrospective analysis of the theatre logbook of the MMU KAF between 1 February 2007 and 31 October 2008. During that period, 1778 operations were done for 1639 patients. A total of 563 local civilians (34% of all patients) were operated on. Oral and maxillofacial surgeons were involved in 322/1778 (18%), general surgeons in 943/1778 (53%), and orthopaedic surgeons in 716/1778 (40%) of operations. Neurosurgeons were present only between March and October 2008, resulting in them being involved in 73/789 procedures (9%). Debridement and closure of wounds were the most common procedures in all specialties. A total of 247 operations on the face, neck, and scalp made up 16% of the total operations for trauma (n=1556), but most for coalition service personnel (n=69, 24%). Only 28 operations (10%) on coalition service personnel were done on the torso. This could be accounted for by the increased numbers of blast injuries and the effectiveness of modern body armour among coalition forces. Brain injuries were also more common among this group of patients than among the other groups, showing that helmets have only a limited effect in protecting against the effects of blast injury. Of all procedures, 163 operations (9%) were done for children. Training of general surgeons is becoming more specialised, which may result in greater dependence on larger teams of subspecialists (including oral and maxillofacial surgeons) in future conflicts.
Asunto(s)
Campaña Afgana 2001- , Hospitales Militares , Procedimientos Quirúrgicos Orales/estadística & datos numéricos , Heridas y Lesiones/cirugía , Adolescente , Adulto , Traumatismos del Brazo/cirugía , Traumatismos por Explosión/cirugía , Lesiones Encefálicas/cirugía , Niño , Desbridamiento/estadística & datos numéricos , Traumatismos Faciales/cirugía , Femenino , Fijación de Fractura/estadística & datos numéricos , Cirugía General/estadística & datos numéricos , Dispositivos de Protección de la Cabeza , Humanos , Traumatismos de la Pierna/cirugía , Masculino , Personal Militar/estadística & datos numéricos , Traumatismos del Cuello/cirugía , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Procedimientos Ortopédicos/estadística & datos numéricos , Estudios Prospectivos , Equipos de Seguridad , Estudios Retrospectivos , Cuero Cabelludo/lesiones , Traumatismos Torácicos/cirugíaRESUMEN
Blast trauma is the primary cause of maxillofacial injury sustained by British service personnel on deployment, and the mandible is the maxillofacial structure most likely to be injured in combat, but there are few reports about the effect of blast trauma on it. The Joint Theatre Trauma Registry identified all mandibular fractures sustained by British servicemen secondary to blast injury between 1 January 2004 and 30 September 2009. These were matched to corresponding hospital notes from the Royal Centre for Defence Medicine (RCDM) for those evacuated servicemen and autopsy records for those who died of wounds. Seventy-four mandibular fractures were identified in 60 servicemen. Twenty-two soldiers were evacuated to the RCDM and the remaining 38 died from wounds. Fractures of the symphysis (39/106, 37%) and body (31/106, 29%) were more common than those of the angle (26/106, 25%) and condyle (10/106, 9%). This pattern of injury differs from that of civilian blunt trauma where the condyle is the site that is injured most often. Those fractures thought to result from the blast wave itself usually caused simple localised fractures, whereas those fractures thought to result from fragments of the blast caused comminution that affected several areas of the mandible. The pattern of fractures in personnel injured while they were inside a vehicle resembled that traditionally seen in blunt trauma, which supports the requirement for mandatory wearing of seat-belts in the rear of vehicles whenever tactically viable. All mandibular fractures in servicemen injured while in the turret of a vehicle had evidence of foreign bodies or radio-opaque fragments as a result of their exposed position. Many of these injuries could therefore be potentially prevented by the adoption of facial protection.
Asunto(s)
Campaña Afgana 2001- , Traumatismos por Explosión/complicaciones , Fracturas Conminutas/etiología , Guerra de Irak 2003-2011 , Fracturas Mandibulares/etiología , Fracturas Mandibulares/patología , Personal Militar , Afganistán , Fracturas Conminutas/patología , Humanos , Irak , Masculino , Protectores Bucales , Cinturones de Seguridad , Reino UnidoRESUMEN
The maxillofacial injuries sustained by British troops requiring aeromedical evacuation to the United Kingdom are almost exclusively treated at The Royal Centre for Defence Medicine in Birmingham. As a result the Maxillofacial Department has collectively gained extensive experience in the management of ballistic injuries. In many cases the most successful outcomes have been achieved by using traditional strategies combined with contemporary techniques. This paper will highlight the types of injuries sustained and discuss some cases that typify those the department has managed.
Asunto(s)
Traumatismos por Explosión/complicaciones , Fijadores Externos , Técnicas de Fijación de Maxilares , Fracturas Maxilomandibulares/etiología , Fracturas Maxilomandibulares/cirugía , Personal Militar , Campaña Afgana 2001- , Traumatismos por Explosión/diagnóstico por imagen , Trasplante Óseo , Implantes Dentales , Humanos , Fracturas Maxilomandibulares/diagnóstico por imagen , Masculino , Radiografía , Fractura Craneal Deprimida/complicaciones , Fractura Craneal Deprimida/diagnóstico por imagen , Traumatismos de los Tejidos Blandos/cirugíaRESUMEN
The aim of this review was to assess the workload of theatres in the role 3 Multinational Field Hospital in Kandahar, Afghanistan and to identify what period of day most emergency admissions arrived. During the period 05 August 2006 to 21 December 2006, 288 operations were performed on 259 patients and comprised 393 individually quantifiable procedures. 98% of these operations were to treat acute injuries. Oral and Maxillofacial surgeons were involved in 24% of operations. 63% of procedures done at these operations involved upper or lower limbs, 19% the head and neck and 18% involved the torso. An analysis of emergency admissions in November 2006 showed that most occurred between 18.00 and midnight. Although theatre timetabling made provision for this, whenever possible, elective surgery was scheduled for the following morning when emergency injury admissions were at their lowest.
Asunto(s)
Campaña Afgana 2001- , Traumatismos por Explosión/cirugía , Hospitales Militares/estadística & datos numéricos , Traumatismos Maxilofaciales/cirugía , Procedimientos Quirúrgicos Orales/estadística & datos numéricos , Traumatismos por Explosión/epidemiología , Canadá , Desbridamiento/estadística & datos numéricos , Humanos , Incidencia , Traumatismos Maxilofaciales/epidemiología , Procedimientos Ortopédicos/estadística & datos numéricosRESUMEN
Drill-free bone screws are a simple and quick method of establishing intermaxillary fixation requiring a minimum amount of specialist training or equipment. These screws offer significant advantages over other methods of intermaxillary fixation and are well suited for use in military casualties.
Asunto(s)
Tornillos Óseos , Fijación de Fractura/instrumentación , Fracturas Maxilomandibulares/cirugía , Personal Militar , Guerra , Humanos , Fracturas Maxilomandibulares/etiologíaRESUMEN
A simple method of providing skeletal anchorage in maxillary distraction is described. The method utilizes cheap and readily available miniplates and provides rigid fixation to the fragment. It can be utilized at multiple levels in high-level osteotomies and situations with an inadequate dentition for anchorage.
Asunto(s)
Placas Óseas , Maxilar/cirugía , Osteogénesis por Distracción/instrumentación , Hilos Ortopédicos , Diseño de Equipo , Humanos , Miniaturización , Osteotomía/instrumentación , Acero InoxidableRESUMEN
A case of cutaneous horn of the lower lip is presented. The paper highlights the need for careful management of such lesions due to the high incidence of malignant or premalignant histology.
Asunto(s)
Queratosis/patología , Leucoplasia Bucal/patología , Enfermedades de los Labios/patología , Neoplasias de los Labios/patología , Humanos , Queratosis/cirugía , Leucoplasia Bucal/cirugía , Enfermedades de los Labios/cirugía , Neoplasias de los Labios/cirugía , Masculino , Persona de Mediana EdadRESUMEN
A case is reported of a glioma of the parietal lobe in which the early symptoms mimicked dental pain and led the patient to consult his dental practitioner in the first instance. The need for careful investigation of unusual presentations of facial pain is stressed.
Asunto(s)
Neoplasias Encefálicas/diagnóstico por imagen , Dolor Facial/etiología , Glioma/diagnóstico por imagen , Lóbulo Parietal , Adulto , Neoplasias Encefálicas/complicaciones , Craneotomía , Diagnóstico Diferencial , Glioma/complicaciones , Humanos , Masculino , Parestesia/etiología , Tomografía Computarizada por Rayos X , Nervio Trigémino/fisiopatologíaAsunto(s)
Fracturas Maxilares , Personal Militar , Enfermedades Profesionales , Adulto , Humanos , Luxaciones Articulares , Masculino , Fracturas Maxilares/clasificación , Fracturas Maxilares/patología , Hueso Nasal/lesiones , Tabique Nasal/lesiones , Enfermedades Profesionales/patología , Fracturas Craneales/patologíaRESUMEN
An appliance is described for the rehabilitation of patients following hemimandibulectomy. It has the advantages, over traditional prostheses, of being quick, simple and cheap to produce.