Management of Maxillofacial Gunshot Injuries with Emphasis on Damage Control Surgery During the Yemen Civil War. Review of 173 Victims from a Level 1 Trauma Hospital in Najran, Kingdom of Saudi Arabia

Abstract

Study Design: Studies on the concept of Damage Control Surgery (DCS) in the management of firearm injuries to the oral and maxillofacial region are still scarce, hence the basis for the current study. Objectives: The objectives of the current study is to share our experience in the management of maxillofacial gunshot injuries with emphasis on DCS and early definitive surgery. Methods: This was a retrospective study of combatant Yemeni patients with maxillofacial injuries who were transferred across the border from Yemen to Najran, Kingdom of Saudi Arabia. Demographics and etiology of injuries were stored. Paths of entry and exit of the projectiles were also noted. Also recorded were types of gunshot injury and treatment protocols adopted. Data was stored and analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp). Results: A total of 408 victims, all males, were seen during the study period with 173 (42.4%) males sustaining gunshot injuries to the maxillofacial region. Their ages ranged from 21 to 56 years with mean + SD (27.5 + 7.6) years. One hundred and twenty-one (70.0%) victims had extraoral bullet entry, while 53 (30.0%) victims had intraoral entry route. Ocular injuries, consisting of 25 (14.5%) cases of ruptured globe and 6 (3.5%) cases of corneal injuries, were the most commonly associated injuries. A total of 78 (45.1%) hemodynamically unstable victims had DCS as the adopted treatment protocol while early definitive surgery was carried out in 47(27.2%) hemodynamically stable victims. ORIF was the treatment modality used for the fractures in 132 (76.3%) of the victims. Conclusions: We observed that 42.4% of the war victims sustained gunshot injuries. DCS with ORIF was the main treatment protocol adopted in the management of the hemodynamically unstable patients.

Introduction

Oral and maxillofacial gunshot injuries pose a significant challenge for reconstructive surgeons who are faced with a mixture of extensive soft tissue and bone defects.[1,2] These tissue injuries are triggered during wars and conflicts, aggression, accidents and suicide attempts. Each of them exhibiting particular characteristics in terms of type of fire- arm used.[3] It has been reported that greater tissue damage is not necessarily caused by high speed projectile with larger kinetic energy. But rather, injury pattern depends on many factors including; kinetic energy, deformation capability, bullet fragmentation and resistance to deformation exhib- ited by involved tissue.[4] In war and armed conflicts where semi-automatic and automatic weaponry are used, the high speed generated in a projectile can produce bone fragments which will also exit as projectiles in the direction of the bullet’s entrance creating secondary missiles. The projec- tile itself might become deformed or fragmented, causing a greater damage to the soft tissue.[5] With this pathophysiol- ogy, the extent of soft tissue destruction in the immediate post injury may not be totally apparent because there is extensive tissue necrosis, ischemia and potential infection.[1] Past management protocol of ballistic injuries have adopted the delayed definitive reconstruction policy based on the pathophysiology of ballistic injury. How- ever, recent evidences have favored immediate and defi-nitive reconstruction.[6,7]

Damage Control Strategies which involves Damage Control Resuscitations (DCR) and Damage Control Sur- gery (DCS) have recently been emphasized.[8,9] DCR is the non-surgical technique to reverse the lethal triad of the combination of acidosis, coagulopathy and hypothermia that usually follows hemorrhage from such injuries. DCS involves immediate hemorrhage control, reduction of con- tamination and temporary wound closure which should be initiated simultaneously with the involvement of all medi- cal personnel in trauma management.[10,11] Studies have shown the benefit of combined DCR and DCS in the man- agement of maxillofacial and neck trauma.[12,13]

The current review is to share our experience in the management of gunshot injuries to the maxillofacial region adopting the DCS and early definitive surgical intervention protocols during the Yemeni civil conflict.

Materials and Methods

This cohort study was carried out between December, 2015 and December, 2019 on combatant Yemeni patients who sustained oral and maxillofacial injuries and were trans- ferred across the border from Yemen to King Khalid Hospital, a tertiary referral center in Najran, Kingdom of Saudi Arabia. Ethical approval was obtained from the hos- pital research and ethics committee (IRB) with protocol number H-II-N-081. Inclusion criteria are patients with gunshot injuries as a result of the civil conflict in Yemen.

Information such as etiology of injury, age and sex were retrieved from the daily data of the accident and emergency department. Classification of anatomical zones of the neck was based on Monson classification [14] where Zone 1 extends from clavicles to cricoid, zone II from cricoid to angle of mandible, and zone III from angle of mandible to skull base. Entry and exit of the projectile were also noted. Also recorded were types of gunshot injury namely; pene- trating, perforating, avulsive and combination and the adopted treatment protocols such as DCS, early definitive surgery, closed reduction and fixation as well as conserva- tive management.

Data was stored and analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp). Results were presented as simple frequencies and descrip- tive statistics. Pearson Chi-square statistics was used to compare categorical variables. Statistical significance was set at p ≤ 0.05.

Results

A total of 408 adult maxillofacial trauma patients was seen during the study period with 173 (42.4%) victims having gunshot injuries. All the victims were males. The ages ranged from 21 to 56 years with mean + SD (27.5 + 7.6) years. The majority of the patients were between the age 21 and 30 years (140 (80.9%)) with the age group 21-25 years constituting the highest frequency (100 (57.8%)). This however, did not attain any statistically significant difference (χ² ¼ 5.602, df ¼ 5, p value ¼ 0.347) when age group was compared with entry of the projectile (

Table 1. Distribution of Mechanisms of Gunshot Injury According to Age Group of the Victims.

	Entry of gunshot injury
Age group		Extraoral
(years)	Intraoral (%)	(%)	Total (%)
21-25	28 (16.2)	72 (41.6)	100 (57.8)
26-30	12 (6.9)	28 (16.2)	40 (23.1)
31-35	2 (1.1)	6 (3.5)	8 (4.6)
36-40	4 (2.3)	6 (3.5)	10 (5.8)
41-45	5 (2.9)	3 (1.7)	8 (4.6)
>45	1 (0.6)	6 (3.5)	7 (4.1)
Total	52 (30.0)	121 (70.0)	173 (100.0)

χ² ¼ 5.602, df ¼ 5, p value ¼ 0.347.

). One hundred and twenty-one (70.0%) victims had extraoral entry of the bullet, while 53 (30.0%) victims had entry of the bullets via an intraoral route (Table 1).

Perforating injury type was mostly observed in the study population in 99 (57.3%) of the victims (

Table 2. Distribution of Blast Injury Zone According to Injury Type and Maxillofacial Bones Affected.

		Injury Zone
	Zone 2 (%)	Zone 3 (%)	Total (%)	Statistics
Injury type				χ2 ¼ 0.757, df ¼ 3, p value ¼ 0.860
Penetrating	4 (2.3)	42 (24.3)	46 (26.6)
Perforating	7 (4.1)	92 (53.2)	99 (57.3)
Avulsive	1 (0.6)	25 (14.4)	26 (15.0)
Combination	0 (0.0)	2 (1.1)	2 (1.1)
TotalMaxillofacial bones affected	12 (7.0)	161 (93.0)	173 (100.0)	χ2 ¼ 19.285, df ¼ 10, p value ¼ 0.037*
Mandible	3 (1.7)	52 (30.1)	55 (31.8)
Maxilla	0 (0.0)	12 (6.9)	12 (6.9)
Zygoma	0 (0.0)	3 (1.7)	3 (1.7)
Orbit	0 (0.0)	24 (13.9)	24 (13.9)
Antrum	0 (0.0)	7 (4.1)	7 (4.1)
MOZ	0 (0.0)	6 (3.5)	6 (3.5)
MMZ	0 (0.0)	4 (2.3)	4 (2.3)
ZM	2 (1.1)	3 (1.7)	5 (2.9)
MM	0 (0.0)	11 (6.3)	11 (6.3)
CZ	0 (0.0)	2 (1.1)	2 (1.1)
None	7 (4.1)	37 (21.3)	44 (25.4)
Total	12 (7.0)	161 (93.0)	173 (100.0)

Key: MOZ (Maxilla/Orbit/Zygoma), MMZ (Maxilla/Mandible/Zygoma), ZM(Zygoma/Maxilla), MM (Maxilla/Mandible), CZ (Condyle/Zygoma). *Statistically significant.

). Indivi- dually, the most affected bones in the maxillofacial region were mandible with 55 (31.8%) cases, orbits 24 (13.9%) cases and maxilla 12 (6.9%) cases respectively while, among the cases affecting multiple bones, combined trauma involving both mandible and maxilla was the majority with 11 (6.3%) of cases. Other maxillofacial bones affected were as shown in Table 2.

In 78 (45.1%) victims who were hemodynamically unstable, DCS was adopted as the treatment protocol while early definitive surgery was carried out in 47 (27.2%) hemodynamically stable victims. ORIF was the leading treatment modality in 132 (76.3%) of the victims irrespective of whether DCS or early definitive surgery was the treatment protocol adopted (

Table 3. Distribution of Treatment Type According to Surgical Procedure.

Surgical procedure	Damage control surgery (%)	Aggressive surgery (%)	None (%)	Total (%)
Exploration and pellet removal	36 (20.8)	16 (9.3)	0 (0.0)	52 (30.1)
ORIF	49 (28.3)	31 (17.9)	0 (0.0)	80 (46.2)
Conservative	0 (0.0)	0 (0.0)	29 (16.8)	29 (16.8)
Closed reduction	0 (0.0)	0 (0.0)	12 (6.9)	12 (6.9)
Total	85 (49.1)	47 (27.2)	41 (23.7)	173 (100.0)
χ2 ¼ 272.560, df ¼ 12, p value ¼ 0.000*.

).

Ocular injuries comprising ruptured globe which makes up of 25 (14.5%) cases and corneal injuries making up of 6 (3.5%) cases, were the most commonly associated injuries.

Other associated injury distribution is as shown in Figure 1. In terms of complications, plate exposure 15 (8.0%), wound dehiscence 10 (5.8%) and surgical/injury site infec-tion 7 (4.0%) were observed. Two (1.2%) victims expired as a result of severe head injury (Figure 2).

Discussions

Our observed epidemiology is consistent with the literature where young adults between ages of 21 and 30 years were the main victims of the conflict. Similarly, only males were seen as victims of the conflict. Studies have shown that males constitute greater than 80% of the gunshot injury patient population.[15] In most war/conflict situations, bomb blast injuries have been reported to be higher than gunshot injuries because of advances in more bomb blast weapon system that can cause more extensive damage.[16] Our cur- rent study showed a lower gunshot injury victims (42.4%) as compared with bomb blast injuries that was observed to be 57.6%. Similar lower incidence of gunshot injuries have also been reported in the literature.[17,18]

The mandible, which is the only mobile bone in the craniofacial complex and most prominent after zygoma,[19] was observed to be most commonly affected in the current study, accounting for 55 (31.8%) of the victims. The mand- ible is therefore more prone to direct forces and injuries because of lack of protection and its large surface area, making it easily exposed to injury.[20,21,22] Comminution of hard tissues (Figure 3A-E) and avulsion of both hard and soft tissues (Figure 4A-H), which are common with fire- arms injuries, were also observed in this group of patients.

Midface injuries, involving the maxilla, zygoma, orbit and NOE, were the second most affected after the mandible (Figure 5A-E). This is also in agreement with reports in the literature[23] but contrary to other studies from war data which have reported the midface to be the commonest zone of injuries.[24,25]

Many maxillofacial firearm injuries can be treated early despite the fact that these wounds are considered contami- nated. Numerous researchers have expressed contrary opin- ion to traditional protocol of delaying surgical intervention and have proposed a comprehensive early primary surgical treatment.[26,27,28] The group also reported that delaying the procedure increased the incidence of wound contracture and fibrosis which resulted in extensive structural and func- tional disfigurement. Advocates of delayed reconstruction have typically argued that the delay period will reduce infection rate, decrease the amount of necrotic tissues, lead to resolution of edema, and decrease inflammation for proper tissue assessment.[29] For the immediate reconstruc- tion group, they have reported that by immediately reduc- ing or eliminating local dead space, there is improved immunoreactivity, delivery of more nutrients necessary for healing to progress, tissues are more elastic and pliable, and finally, there are fewer and less complex secondary procedures.[27,28]

DCS, also referred to as salvage surgery, has been in the frontline in the management of trauma patients especially when they are not clinically fit for a prolonged surgery required for extensive soft and hard tissue reconstruc- tion.[8,11] We reported that 78 (45.1%) victims were treated with the DCS and 47 (27.2%) by immediate definitive repair with ORIF. In the victims who were too hemodyna- mically unstable to withstand prolonged surgery for definitive reconstruction, we applied DCS by initial explo- ration of soft tissue wounds to control bleeding and later when the patients’ condition improved, ORIF of bony frac- tures. The ORIF was carried out by initially picking viable bone pieces and aligning them with the use of wires, micro- plates and/or use of flexible 2.0 mm miniplates and later reinforcing the aligned segments with rigid 2.0 mm mini- plates, 2.4 mm miniplates or sometimes, 3 mm reconstruc- tion plates (Figure 6A-F). Literature search has revealed only 2 reported studies that specifically explained the appli- cation of DCS in maxillofacial surgery but unfortunately they did not discuss which procedures should be used spe- cifically for the maxillofacial trauma.[30,31] From the authors’ point of view, the idea of DCS may operate as a compromise between delayed and early definitive manage- ment. In the current study, hemodynamically stable victims were treated by early definitive management with ORIF and soft tissue repair. This approach is consistent with the early surgical intervention of maxillofacial ballistic injuries reported in the literature. Recent evidences have shown that in the maxillofacial region, many ballistic injuries may be treated early with improved re-establishment of the facial contours, lesser morbidity, early return to function, shorter hospitalization, and reduced need for secondary procedures.[6,7,26,32]

Ocular trauma was observed as the mostly commonly associated injury in the current study which is in tandem with the literature.[25,33,34] We reported 25 (14.5%) victims with ruptured globe which required enucleation and evis- ceration, 6 (3.5%) had corneal lacerations that were sutured and abrasions that were managed with topical dressings by the ophthalmologists. Furthermore, these patients were under constant reviews by the ophthalmologists in the eye clinic. Because of the high incidence of ocular injuries in ballistic missile trauma to the craniofacial complex, the United States of America and United Kingdom military forces have resorted to the use of low- and medium-impact ballistic sunglasses and goggles.[35] Other associated injuries in our study were attended to in a multi-specialty manage- ment protocol for war victims received by our hospital. This include psychologists and psychiatrists for the management of anxiety and depression, Post-Traumatic Stress Disorder (PTSD), low self-esteem and low quality of life (QoL) that are usually associated with such injuries. Secondary proce- dures planned for reconstruction in these patients were suspended because of the high turnover rate of patients for emergency surgery during the conflict. Inability to reha- bilitate them to full oral function with dental treatments including implant-retained prosthesis was a major treatment gap observed in these group of patients. Nonetheless, appro- priate and detailed medical report were provided to all patients returning to their country for follow-up.

Conclusions

Firearms injuries will continue to be a public health chal- lenge in the current world situation. From the current study, all the victims of gunshot injuries in the ongoing Yemen conflict were males with the majority in the 21-30 years age group. Fifty-three (30.0%) victims had intraoral entry of the bullets which is suggestive of sniper tactics while others were victims from battle field gunshot injuries. The major- ity of the victims were managed by DCS which involved initial exploration to control soft tissue bleeding as well as temporary fixation of bone fragments followed later by definitive ORIF of bony fractures. Ocular trauma was the most observed associated injury. Multi-disciplinary man- agement protocol was adopted for the victims including psychologists and psychiatrists for the management of anxiety and depression, post-traumatic stress disorder low self-esteem and low quality of life.