Facial Trauma Limb Fractures for soft tissue cover Foot Trauma Fractures of the Jaws & Facial limbs
Orthopaedic support in limb traumas and Orthodontic and Prosthodontic
help for Maxillofacial trauma is readily available.
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Few injuries are as challenging as the injuries of the face. Surgeons have a dual
responsibility : repair of the aesthetic defect and restoration of facial
functions. Not only is the regaining of the pre-injury appearance important
for the sagging self esteem of the injured patient but all those functions
of the various parts of the face which one takes for granted in life
like smiling, seeing, tasting, chewing, swallowing and talking are effected
and retrieving their pre-injury status is of paramount importance.
A face is home to all the five sensory organs of the body as well as our
means of identity in the society. The most important part of the body
needs the attention of the most qualified persons in the health pyramid
as a prompt and definitive reconstructive programme, started as early
as possible, is the only deciding factor between a good result – which
should go unnoticed in the society, and an average result – which will
attract unwanted attention.
A patient with facial injury often sustains other injuries as well, some
of which may be life threatening, viz. Head injury, Chest injury, Spinal
injury etc. and definitive care of facial injury must wait until these
have been properly attended and treated. While motor vehicle accidents
are the commonest cause of major facial injuries minor injuries can
follow domestic accidents, trivial altercations and outdoor sports.
At the site of injury an injured victim if unconscious, should have his
airways cleared and head turned to one side.
Bleeding should be controlled by gentle pressure and an ambulance called for early transportation to a hospital or a trauma centre. A conscious
patient should be reassured and made to sit up, if he can do so
comfortably, as they tend to bleed more while lying down. They should be
given nothing by mouth as they may require an emergency surgery which
may in turn require general anaesthesia.
Every management programme should start after ensuring that the victim has a
clear airway, is breathing properly and has a stable circulation.
Accompanying persons should be reassured and advised about
voluntary donation of blood for the victim if required. Every
injured patient should have a tetanus prophylaxis and an antibiotic
coverage and he or she should be made pain free as soon as possible.
A proper photographic documentation of the injury and a radiological
assessment of the facial skeleton is next on the agenda. With the advent
of CT Scans and more recently a new software which can produce a
3D CT image of the facial skeleton, facial fractures can be best
diagnosed by this method whenever suspected.
Now is the time to gather the required multi-disciplinary team and to
reassess the patient and arrive at a diagnosis. Facial injuries can be
injuries to the soft tissues alone or a combination of soft tissue
injuries and facial fractures, or facial fractures alone. With a Plastic
Surgeon as the main anvil of the team, help can be sought from an ENT
surgeon, a Neurosurgeon or an Ophthalmologist depending upon the
nature of injury.
Subsequently once the wounds have healed and the
swelling subsided the help of a prosthodontist for some missing teeth or
an orthodontist for minor problems in occlusion may be sought. Last but
not the least, the psyche of the injured person should never be
forgotten and a friendly Psychiatrist can do wonders by boosting his
Injuries in the face can be contusions, abrasions, lacerations, deep lacerations
with underlying Facial nerve or salivary gland / duct injury, avulsion
of a part of the face, burn injury or ballistic injury with a
through and through hole in the mouth. A simple black eye could be
hiding a serious underlying fracture of the orbital floor or zygoma. A
small puncture wound may be leading into the eye or even the brain. A
small area of numbness or inability to chew with previous ease may
actually be because of a jaw fracture.
Because of such complexities in
presentation this is not the domain of amateur interventionists.
Every part of the avulsed face or cut nose or amputated ear should be put in a
polybag, which in turn should be put in an ice box or a flask containing
ice and rushed to the hospital. If arteries and veins can be identified
under an operating microscope these pieces can be replanted, if they are
well preserved, and if the injury is fresh.
Parents should realize that what they perceive as a small cut is, if nothing
else, a cosmetic blemish. Yelling children should not be pinned
down by overpowering relatives while an equally irritated doctor tries
to put a few stitches in it in his own clinic in local or vocal
anaesthesia. We need better preparation, better sterilization,
better anaesthesia, better environment, better magnification and better
suture materials for better results.
Parents should also realize that, no matter what they read in magazines or hear
in soap operas, no surgery has yet been invented in this world that does
not leave any scars. Scar-less surgery is a myth, the fact is that we
start scarring from the third month of our existence in our
mother’s womb. We inherit the scarring qualities from our parents and
none of us scar the same way. As a cosmetic surgeon our job is to
camouflage the would be scars in the lines of facial expression so that
they do not stand out in an animated face.
Some suture-less surgeries are now available where skin sutures are being
replaced by either strips of adhesive dressing materials or by a fibrin
glue. These also leave behind scars and have in no way proved to be
superior to a good suture technique. The decision to use them should
certainly rest with the surgeon in charge.
No management programme is complete without a word about prophylaxis. Automobile designers have come up with seat belts, padded dashboards, multi-laminated windshield and improvement in the design of rearview mirrors and steering wheels.
Helmets for two wheelers is a must as is keeping a cool head
on the roads. In the end I can not stop myself from emphasizing
that – ‘ If you drink and drive, you are an idiot ‘.
Limb Fractures for soft tissue cover Open fractures of the Tibia, significantly displaced, severely comminuted, resulting from high energy forces, are usually associated with extensive skin loss and devitalized muscles. There is often an element of crush and degloving and at times a vascular injury which needs primary repair for limb salvage.
After thorough debridement and skeletal stabilization using external
fixators the defect in the integument need to be addressed. In
Gustillo Anderson Type II injuries in the upper and middle third of leg
a pedicled myocutaneous flap from the calf is often enough to provide a
stable cover. However in Type III and IV injuries and particularly in
injuries involving the lower third of leg a microvascular free tissue
transfer of skin, muscle and, if required, bone provides us with the
best possible solution.
The restoration of the cutaneous covering is the primary surgical requisite
because deep healing can be no better than the surface covering.
Vascularized bone grafts also assist the bony healing on occasions when
there is appreciable bone loss.
Limb Salvage & Limb Reconstruction Using Microsurgery
Microsurgery in the lower limb is of four types:
Mangled Extremity Severity score:
This is a scoring system which decides whether the injured limb is salvageable.
Four factors are scored:Skeletal
and Soft tissue injuryLimb
ischemia time Shock Age of the victim and a score is reached. This score is doubled if the ischemia time is more
than 6 hours. The lower the score the better are the chances of success
of a replantation / revascularization surgery.
Preservation and Transportation Proper preservation in a poly-bag which in turn is put in an ice box / another
poly-bag containing ice with a time label is essential. The part
should not come in direct contact with ice and should not be immersed in
any antiseptic solution or tissue preservatives. All dismembered parts
should be sent as non salvageable parts form an important source of skin
and fascial flaps and artery, vein, nerve, tendon and bone graft. The
part can be sent before the patient so that work can start while the
victim is being resuscitated for other accompaning injuries. So for
transportation the three golden rules areDO IT QUICKLYDO IT PROPERLY SEND ALL DISMEMBERED PARTS
Aims of managing a mangled extremityAN
AESTHETICALLY ACCEPTABLE SKIN COVERGOOD
AND EARLY HEALING OF BONEGOOD
MOVEMENT OF CONTIGUOUS JOINTS
While salvaging lower limbs special care should be taken in decision making.
The answer to be sought is not whether the limb will survive but whether
the limb will function usefully.
We would only go ahead with limb salvage if the Tibial nerve is
preserved or its recovery is assured. Choice of flap is not the limiting
factor of limb preservation but the sensibility of the sole of the
IF SOLE OF FOOT DOES NOT GAIN SENSATION
THE REPLANT THOUGH SUCCESSFUL ANATOMICALLY IS A FUNCTIONAL FAILURE
Plan of management:
ASSESSMENT OF DEFECT IN 3 DIAMENSIONS
THE CHOICE OF FLAP
TENDON AND NERVE REPAIR
we prefer muscle flaps?
MUSCLE BRINGS BETTER VASCULARITY
CONTAINS SUBCLINICAL SEPSIS
MOULDS WELL TO THE DEFECTS
FILLS IN CAVITIES
SUPPORTS CANCELLOUS BONE GRAFTS
ATROPHIES PREDICTABLY-BETTER SHAPEChoice
of tissue transferred
depends on the type of tissue lost:
Muscle + integument loss
and soft tissue loss
RADIAL FOREARM FLAP
SOLEAL FLOW-THROUGH FLAP
LESS THAN 8 cm. – FREE ILIAC CREST
MORE THAN 8 cm. – FREE FIBULA
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