Basic principles of PSD
Primary surgical debridement is the first surgical intervention for a gunshot wound. The main goal is to clean the wound of necrotic masses and restore blood circulation.
According to the military-medical doctrine (by A.V. Lukyanenko), care must be single-stage and include:
- Fixation of bone fragments.
- Closure of soft tissue defects.
- Through-and-through irrigation drainage.
In the postoperative period, intensive therapy is mandatory: replacement of blood loss, correction of microcirculation and electrolyte balance.
Preparation and antiseptic treatment
Before surgery, painful antiseptic treatment is always performed, requiring prior anesthesia.
- Skin cleansing: hydrogen peroxide (2–3%), ammonia solution (0.25%), or iodobenzine (excellently dissolves blood and fat) are used.
- Wound irrigation with antiseptics to remove small foreign bodies.
- Shaving hair around the wound.
- Repeated washing and drying.
- Final skin treatment with 1–2% iodine tincture.
Features of bone tissue management
Bone management is the initial stage of PSD. Tissues are treated with care:
- Small free bone fragments are removed.
- Fragments connected to soft tissues are placed back. However, if their rigid fixation is impossible, they must be removed (the principle of "moderate radicality"), as mobile fragments become necrotic and cause osteomyelitis.
- Teeth with exposed roots at the ends of fragments are removed.
In high-velocity weapon injuries, large fragments often die due to hypoxia and impaired intraosseous microcirculation, turning into sequestra. Therefore, on the mandible, the edges are not simply bitten off, but fragments are sawn off until capillary bleeding appears, exposing viable tissue.
Tactics for maxillary trauma
Maxillary injuries require exploration of adjacent cavities: the maxillary sinus, nasal passages, and ethmoidal labyrinth.
- Maxillary sinus: clots, foreign bodies, and damaged mucosa are removed. Viable mucosa is placed onto the bone and fixed with an iodoform tampon. An anastomosis with the inferior nasal meatus (antrostomy) must be formed for drainage and washing.
- Hard palate: attempts are made to close the wound defect with a pedicled flap (from the cheek, lip, palate). If this is impossible, a protective acrylic plate is used.
- Nasal cavity: when the nasal passages are destroyed, the prevention of basal meningitis is important. After repositioning the fragments, tubes wrapped in gauze are inserted into the nasal passages up to the choanae to ensure breathing and fix the mucosa.
Briefly: answers to topical questions
What osteosynthesis methods are used for rigid fixation of fragments in gunshot fractures of the jaws?
In gunshot fractures of the jaws, a compression-distraction device is used for fragment fixation, while certain other methods are contraindicated.
- Compression-distraction device — brings fragments into contact, reduces the size of the intraoral wound, and allows osteoplasty to be started immediately after surgical debridement.
- Osseous suture — is an absolute contraindication in gunshot injuries of the jaws.
What are the indications for removing teeth from the fracture line in gunshot jaw injuries?
In gunshot injuries and fractures of the jaws, teeth are subject to removal if their roots are exposed, if there are pathological changes, or if they present mechanical obstacles.
- Root exposure — teeth located on the ends of bone fragments with exposed roots are removed.
- Pathological changes — fracture or dislocation of the root, exposure of cementum, tooth mobility, presence of a granuloma.
- Maintenance of inflammation — if the tooth maintains inflammatory phenomena despite ongoing therapy.
- Mechanical obstacle — teeth that interfere with the apposition of bone fragments.
What types of drainage are used after PSD of maxillofacial gunshot wounds?
After primary surgical debridement of facial gunshot wounds, two main methods of drainage are used.
- Through-and-through irrigation method — used for prolonged lavage of a gunshot wound with antiseptic or antibiotic solutions via inflow and outflow tubes.
- Prophylactic drainage — performed according to N.I. Kanshin's method for cellular spaces adjacent to the wound in the submandibular region and neck using a double-lumen tube.
What antibacterial drugs are prescribed for infection prophylaxis after facial PSD?
To prevent postoperative infection, several groups of antibiotics are prescribed, starting 30–60 minutes before the incision and continuing until suture removal.
- Penicillins — including inhibitor-protected drugs.
- Cephalosporins — 1st and 2nd generation drugs are used.
- Lincosamides — used as drugs of choice.
- Glycopeptides — also included in the list of recommended agents.
PSD in gunshot wounds: E-S-C (Early, Single-stage, Comprehensive).
Class and exam questions
What is the difference between primary surgical debridement and secondary surgical debridement?
PSD is the first surgery after the injury. Secondary debridement is performed repeatedly if inflammatory complications develop after PSD.
Is primary surgical debridement always necessary for gunshot wounds of the face?
No, about 15% of the wounded at the hospital stage need only wound toilet (removal of foreign bodies, clots, washing) without radical intervention.
How are the edges of mandibular fragments managed in high-velocity injuries?
The ends of fragments are sawn off until capillary bleeding appears. This exposes viable cells for full reparative osteogenesis.
What else to study on this topic
- Features of wound tract exploration and wound toilet.
- Plastic surgery with local tissues and placement of plated sutures on soft tissues.
- Tactics for avulsion of the alveolar part of the jaw.
- Treatment of zygomatic bone fractures (osseous suture).
- Prevention of cerebrospinal fluid leakage and basal meningitis in injuries of the ethmoid labyrinth.
Master the entire topic in the course "Surgical Dentistry"
This is a summary. The course covers everything tested in classes and exams.
- Complete guideline on «Facial Bone Fractures» and 866 more pages on the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 28 video lessons on the subject
Other topics in the section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.