Features of combined facial injuries
Maxillofacial injuries are divided into isolated (bruises, abrasions, wounds of soft tissues only) and combined, in which the disruption of soft tissue integrity is accompanied by bone fractures.
The severity of associated trauma is often determined by the nature of the wounding instrument. For example, a chop wound (vulnus caesum), inflicted by a heavy sharp object, is characterized by significant width and depth, with free bone fragments of the facial skeleton frequently identified within the wound tract. A stab wound (vulnus punctum) has a small entrance opening but a deep tract capable of causing a perforation fracture of the bone or destroying the thin wall of the maxillary sinus.
The rich innervation and vascularization of the face form a specific clinical picture. On the one hand, tissues have a high regeneration potential. On the other hand, there is a high risk of massive bleeding, traumatic shock, and paralysis of the facial muscles if the branches of the facial nerve are damaged.
Diagnostic methods
The examination of patients with combined trauma is comprehensive and includes:
- Probing of the wound canal: allows determining its length and topography relative to vital structures.
- X-ray examination: mandatory when bone damage is suspected. Helps to identify fracture lines of the upper or lower jaw, zygomatic bone, and nose, as well as to detect foreign bodies.
- Vulnerography: X-ray with the introduction of a contrast agent into the wound canal. Used for puncture wounds when conventional probing is impossible.
- Laboratory diagnostics: in case of profuse blood loss (characteristic of chop and puncture wounds), blood is urgently taken to determine blood group and Rh factor before potential blood transfusion.
Principles of surgical treatment
Patients with combined injuries and bone damage are hospitalized on an emergency basis. The mainstay of treatment is primary surgical debridement (PSD) of the wound. The procedure must be radical and performed in a single stage.
Main stages of PSD:
- Toilet of the wound and surgical field (washing with warm water, treatment with antiseptics, shaving of hair).
- Adequate anesthesia (local or general, with mandatory consultation of an anesthesiologist).
- Wound revision with removal of foreign bodies.
- Sparing excision of non-viable (crushed) wound edges.
- Layer-by-layer closure.
The order of suturing is strictly regulated by the anatomical zone. Thus, in penetrating wounds of the oral cavity, the mucous membrane is sutured first, then the muscle, and only then the skin.
Specific consequences and complications
The anatomical features of the face lead to a number of unique surgical problems. When mimetic or masticatory muscles are transected, muscle fibers contract (retraction occurs). This causes severe gaping of the wound, forming a false defect that visually exceeds the real volume of lost tissue.
Other severe consequences include:
- Violation of the hermetic seal of the oral fissure (leads to constant sialorrhea and fluid loss).
- Formation of salivary fistulas (in case of injury to the parotid salivary gland).
- Facial asymmetry due to unilateral post-traumatic edema.
- Development of jaw contractures in the long-term period.
Briefly: answers to topical questions
What types of primary surgical debridement of wounds are distinguished depending on the timing of its implementation?
Depending on the time elapsed since the injury, three types of primary surgical debridement (PSD) of wounds are distinguished.
- Early PSD — performed within up to 24 hours.
- Delayed PSD — performed within up to 48 hours.
- Late PSD — performed 48 hours after the injury.
What standard means are used for transport immobilization in jaw fractures at the pre-hospital stage?
Standard extraoral and intraoral means are used for transport immobilization in jaw fractures.
- Standard soft chin sling by Pomerantseva-Urbanskaya — consists of a chin sling, wide rubber bands, and cloth straps with holes for a cord; not used for fractures of edentulous jaws and in the absence of dentures.
- Standard bandage for transport immobilization — includes a one-size-fits-all cap and a rigid chin sling with slots and protrusions.
- Standard transport splint-tray — used for immobilization of the upper jaw; consists of a standard cap and a metal splint-tray with extraoral rods.
Which main blood vessels provide vascularization of the face and can become a source of massive bleeding?
Vascularization of the face is provided by branches of the external and internal carotid arteries, damage to which can cause massive bleeding.
- External carotid artery (a. carotis externa) — gives off the superficial temporal, occipital, posterior auricular, facial, and maxillary arteries.
- Facial artery (a. facialis) — runs in the subcutaneous tissue of the buccal region and between the facial muscles.
- Maxillary artery (a. maxillaris) — supplies blood to the deep region of the face.
- Superficial temporal artery (a. temporalis superficialis) — supplies blood to the temporal and parietal regions.
- Internal carotid artery (a. carotis interna) — participates in blood supply via the ophthalmic artery (a. ophthalmica).
The main venous drainage collector is the facial vein (v. facialis).
To remember the order of closing a penetrating cheek wound, use the "inside-out" rule: M-M-S — Mucosa, Muscle, Skin. And for the lips, the order is different: Muscle, then the border (red vermilion border), then Mucosa and Skin.
Class and exam questions
In which cases can a primary tight suture be applied?
A primary closed suture is applied if up to 48 hours have passed since the injury. The period can be extended up to 72 hours if the victim immediately started taking antibiotics. At later stages, it is strictly forbidden to apply it.
What is a primary delayed surgical debridement?
This is a primary surgical debridement of a wound performed between 24 and 48 hours after the injury. Its goal is the prevention of infection and the creation of conditions for normal healing.
How should a wound in the area of natural orifices (e.g., the nose) be managed?
Wounds in the area of natural openings are managed on a rubber tube. This is necessary to prevent cicatricial narrowing of the opening after final tissue healing.
What else to study on this topic
- Differential diagnosis of wound types (incised, chop, lacerated, contused, animal bite)
- Indications for outpatient treatment of facial injuries
- Method of reduction of posterior dislocation of the mandible
- Tactics of secondary surgical debridement in purulent complications
- Features of suturing in injury of the parotid salivary gland
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- Complete guidelines on "Combined maxillofacial trauma" and 866 more pages of the subject
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Other topics in the section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"
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