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Eur J Trauma Emerg Surg (2011) 37:41–47 DOI 10.



Diagnostic and therapeutic aspects in the treatment of gunshot wounds of the viscerocranium
¨ be • J. Klatt • M. Heiland • R. Schmelzle A. Gro P. Pohlenz

Received: 11 September 2009 / Accepted: 26 January 2010 / Published online: 11 May 2010 Ó Urban & Vogel 2010

Abstract Gunshot wounds of the viscerocranium are a rare occurrence during times of peace in Europe. The removal of projectiles is recommended; in some cases, however, this is controversial. The material properties of projectiles and destruction of anatomical landmarks make it difficult to determine their precise location. Therefore, navigation systems and cone-beam computed tomography (CT) provide the surgeon with continuous intraoperative orientation in realtime. The aim of this study was to report our experiences for image-guided removal of projectiles, the use of cone-beam computed tomography and the resulting intra- and postoperative complications. We investigated 50 patients with gunshot wounds of the facial skeleton retrospectively, 32 had imageguided surgical removal of projectiles in the oral and maxillofacial region, 18 had surgical removal of projectiles without navigation assistance and in 28 cases we used cone-beam CT in the case of dislocated projectiles and fractured bones. There was a significant correlation (p = 0.0136) between the navigated versus not navigated surgery and complication rate (8 vs. 32%, p = 0.0132) including major bleeding, soft tissue infections and nerve damage. Furthermore, we could reduce operating time while using a navigation system and cone-beam CT (p = 0.038). A high tendency between operating time and navigated surgery (p = 0.1103) was found.

In conclusion, there is a significant correlation between reduced intra- and postoperative complications including wound infections, nerve damage and major bleeding and the appropriate use of a navigation system. In all these cases we were able to present reduced operating time. Cone-beam CT plays a key role as a useful diagnostic tool in detecting projectiles or metallic foreign bodies intraoperatively. Keywords Gunshot wounds Á Projectiles Á Imaging techniques Á Cone-beam computed tomography Á Navigated surgery

Introduction Gunshot wounds of the maxillofacial region are a rare occurrence during times of peace in Europe. Recently, however, there has been a general increase in number and severity of these injuries [19]. They are mainly caused by suicide attempts, violent conflicts or negligent handling [1, 3]. A projectile can contain a variety of materials that show differences in their deformation and fragmentation behavior. Missile characteristics such as flight velocity and rotational velocity, mass, caliber, composition and angle of trajectory all influence the extent of gunshot injuries [2, 7]. The face comprises a complex anatomical arrangement of bone and soft tissues so that the severity and extent of injury may range from a simple wound of soft tissues to a severe combined destruction of the viscerocranium, including the vascular and nervous systems. Even if the gunshot injury itself does not cause major problems, the surgical removal of projectiles can cause damaging of vital anatomical structures. However, conventional radiography, computed tomography, image-guided surgical removal and

¨ be (&) Á J. Klatt Á R. Schmelzle Á P. Pohlenz A. Gro Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany e-mail: M. Heiland Department of Oral and Maxillofacial Surgery, General Hospital of Bremerhaven-Reinkenheide, Postbrookstr. 103, 27574 Bremerhaven, Germany e-mail:

Statistical analysis For statistical analysis SPSS for Windows (Version 11.1) (SPSS Inc. Thirty-two had image-guided surgical removal (Brainlab vector vision2) of projectiles in the facial region. 26]. it has been shown that remaining projectiles may lead to infection [14. 18 had surgical removal of projectiles without navigation assistance. Therefore. 6%) with the thorax and abdomen (n = 3. Germany. Chicago. A. treatment received and complications. The aim of this study was to report our experiences for image-guided removal of projectiles and cone-beam CT in the viscerocranium and whether there is a significant correlation with resulting intra. All patients were being treated at the Department of Oral and Maxillofacial Surgery of the University Medical Center Hamburg-Eppendorf. negligent handling (n = 11. 38%). However. conventional x-ray films alone were Patients and methods We investigated 50 patients retrospectively. n=13 grazing shot. followed by dentoalveolar fractures and soft tissue injuries to the cheek.05.42 ¨ be et al. n=11 shotgun. The main advantage of cone-beam CT over conventional CT is that the images have considerably fewer metal artefacts and is thus able to localise metallic foreign bodies [18]. a grazing shot or because of shotguns (Fig. ranged from simple penetrating wounds of the chin to gross destruction with bony defects (Fig. type and classification of facial injuries. 1 Type of shot causing the injury of the maxillofacial region . the pellets may dislocate within the soft tissue or sinuses spontaneously. 8%). but also for location of projectiles and planning the surgical procedure. the lower third injuries. 88%) had no associated bodily injuries. All patients had soft tissue injuries. Information and patient data were gained from patient files and patient radiographs (conventional radiographs. and it is well known that metal embedded in body tissue can be a source of potential exposure to toxic effects [22. between 1998 and 2008. n=23 22% 46% full penetration. Results In 23 of the cases we had a retained projectile. it does not seem appropriate to leave a pellet as has been proposed previously and is still discussed with controversy [10. On the other hand. No special investigations were required in 8% (n = 4) of the sample. 21] or migrate from the site of the entry [18]. 6%) at least common. suicide attempts (n = 13. including the mandible and its related structures. Even if the exact position is known from imaging data. Gro cone-beam CT have been applied to facilitate that procedure [24. 12].5. conebeam CT and CT scans) retrospectively and were sorted according to the age. 28]. In the middle third of the viscerocranium we had lateral mid-facial fractures (zygomaticoorbital). treatment planning often required different or combined radiographic examinations. 26%) or because of professional reasons (n = 7. 1). 2). neck and limb injuries (n = 3. 6% retained projectile. and supraorbital rim fractures in the upper third and soft tissue injuries to the temple. In 28 of the cases we used cone-beam CT (Siemens Arcadis Orbic 3D) intraoperatively to detect spontaneously dislocated projectiles or evaluate the result of treated boney fractures. USA) was used. the accurate reproduction of this position in the physical space of the patient can be difficult. These injuries constituted the greatest amount of injuries of the viscerocranium in this study. so called navigation systems and cone-beam CT allow the registration of image space and physical space of the patient and give the surgeon continuous real-time orientation intraoperatively. n=3 26% Fig. Depending on the pattern of injury.. 22%). The majority of the injuries were caused by violent conflicts (n = 19. IL. followed by a full penetration. Finally. diagnostic methods. not only to assess the extent of the hard and soft tissue destruction. Moreover. 2). [9] there were frontal bone fractures. in 50% of the cases (n = 25) combined with hard-tissue injuries to the viscerocranium (Fig. Cone-beam CT is a recently introduced imaging technique that uses a cone-beam moving around a part of the body under examination and allows images to be obtained at lower doses of radiation than conventional CT. if the projectile or foreign body is not adjacent to a definite anatomical landmark. 14%). Following the classification of Gant et al.and postoperative complications caused by the surgical procedure. The majority of the sample (n = 44. Significance statements refer to p values of two-tailed tests that were less than 0. facial injuries. gender. Patient ages ranged from 17 to 77 years with a higher frequency in males (39/78%) than in females (11/22%). The most common associated injuries were neurocranium (n = 4.

3 CT scan. 4). the relation of the patients rigid body to the patients anatomy has to be established within the registration-process. 2 Patterns of injury (n = 50) 40% 35% 30% 25% 20% 15% 10% 5% 0% ) ) ) ) ) ) ) ) ) =3 ) =7 =3 =6 =3 =4 17 =2 =2 n= (n =2 (n (n (n (n (n (n (n (n (n w er lip Lo =1 ) 43 ne it ( la e la e la e di bu m an ek e ol us ct ur rb lf os bo he di bu di bu Al ve O nt al fra ra C Te m po Fr o rb m an s m an ita l am us -o pu om at ic o or R C Zy g Fig. Afterwards the registration-process was done by identifying the corresponding positions of the titanium markers in the image data as well as on the patient. It helps to detect the path of the projectile and to preserve surrounding tissues. Navigation systems have an accuracy of ±1 mm [20]. Depending on the material properties of the projectile. for the registration process image data was transferred to the navigation system and the foreign bodies were located and marked within the planning software (Fig. The conventional radiographs and CT-investigations were done in our Department of Radiology. Metal projectiles are radiopaque and can be detected by all radiological examinations. cone-beam CT is well suited to imaging metal projectiles or to evaluate facial fractures and presents a valuable addition to the wide range of diagnostic tools available. Intraoperatively a rigid body is affixed to the patients head with bone screws directly to the skull.2% of CT scans we found pathologic results preoperatively (Fig. the presence of high-density metal objects create artefacts that make it sometimes difficult to obtain accurate information about adjacent anatomical structures. There are differences between the imaging modalities in the presence of artefacts and final imaging quality. Navigation surgery can be performed if either CT or cone-beam CT data sets are available and reference points are identified. navigation-assisted surgery was used. In 70. R am us an d C or pu s C hi n sa . In case of invisibility of the projectiles on physical examination and inspection. 3).Treatment of gunshot wounds of the viscerocranium Fig. Navigation facilitates the surgeon’s orientation to unexposed anatomical structures. Cone-beam CT is a modern imaging technique that has the advantage of being associated with a low level of metal artefacts [29]. a suitable imaging technique should be selected. or if the foreign body was close to vital anatomical structures.8% of all conventional radiographs and 84. showing destruction of the lower jaw after a suicide attempt requested in 18% (n = 9) and in combination with CT scans and cone-beam CT in 74% (n = 37) of the cases. In the case of navigation-assisted surgery. Since CT and cone-beam CT both produce three-dimensional reconstruction images. Despite limitations for soft tissue imaging [8]. For valid tracking.

The overall complication rate was 34%. 5 Intraoperative imaging system (Siemens Arcadis Orbic 3D) for the detection of a fractured lower jaw (a. 2%). 14 vs. 4 Preoperative screenshot from the navigation system showing a triplanar view with the current position of a projectile inside the left orbit ¨ be et al. Table 1). 4%) and nerve damage (n = 3 vs. n = 0.44 Fig. 0%) (Fig. b) All projectiles could be removed via minimally invasive surgical access to the indicated location. Gro Fig.0136) between the navigated surgery versus not navigated surgery and complication rate including major bleeding (n = 4 vs. In 28 of the cases we used a cone-beam CT (Siemens Arcadis Orbic 3D) to reproduce the new position of . 6 vs. 7. The average duration of a not-navigated surgical procedure was 164 ± 73 min versus 120 ± 76 min for a navigated surgical procedure including reference-process. patients were given antibiotics prophylactically. Furthermore there was a significant correlation (p = 0. revision of the gunshot wounds were performed and the defect-fractured jaw was stabilized with a reconstruction plate (Figs. 5. All surgical procedures were uneventful. n = 2.1103). n = 1.038) between the operation time and postoperative complications including mainly wound infections and major bleeding. While using a navigation system we could reduce the operation time. 6). 8 vs. Another finding was the high tendency between operation time and navigated surgery (p = 0. A. there was a significant correlation (p = 0. soft tissue infections (n = 7 vs.

4]. The foreign bodies were found and removed uneventful in all cases. and projectiles often lie close to vital anatomical structures with difficult surgical access. orbit n = 3) or evaluate treated bony fractures (n = 13). violent conflicts and negligent handling. the mean stay was 14. Gunshot wounds often show damaged tissue. Literature on gunshot wounds to the viscerocranium remains scare. 6 Intraoperative situation showing the destruction of soft tissue (a. a sound knowledge of gunshot wounds as well as ballistics. b). Projectiles should be removed surgically whenever possible considering the state of the patient and the location and kind of the foreign body [3.3 days (±7. e). temporal region n = 3. Discussion Gunshot injuries are rare in Western Europe in times of peace. a variety . They are usually the result of suicide. removed projectile (g) and the situation 6 months after treatment (h) 45 spontaneously dislocated projectiles (sinus maxillaris n = 9. the fractured lower jaw with boney defect (c. and a well planned preoperative examination plan are necessary. altered anatomy.9). To identify the exact position of a foreign body and assess the damaged surrounding tissue.Treatment of gunshot wounds of the viscerocranium Fig. For optimal interdisciplinary management a careful clinical examination. d. stabilized jaw (f). All patients were hospitalized for at least 6 days.

H.O. cone-beam CT and C-arm systems are available intraoperatively.S. the techniques used in immediate reconstruction of bony defects caused by .N. carotis comm. 7 Complication rate.M. carotis ext. S. carotis ext. cone-beam CT and C-arm systems are seldom available in oral and maxillofacial operating theaters.M. P. – – – – Major bleeding (A. 29]. the presence of structures at risk close to the foreign body or in the path of the surgical access towards the foreign body. 25]. In all cases projectiles could be identified and in two cases we reconsidered the position of screws because of the introperative cone-beam CT scan result to avoid any further operation. Gro Table 1 Intra. Since it is usually impossible to identify the exact position of a projectile by visual inspection alone. it requires direct contact with the surgical field and increases the risk of contamination. G. facialis) – – – – – – – – – Lesion lingual nerve Lesion facial nerve Lesion inf.J. In these cases navigation based on preoperatively acquired imaging data becomes useless for relocation of a foreign body.M. N. Once the position of the projectile has been located and the extent of the damaged tissue has been assessed.46 complications no complications 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% not navigated navigated ¨ be et al. the detection of projectiles behind bony structures is not possible. further studies are needed. The circumstances that indicated the need of a navigation system were: • • • failure of previous attempts at removal of a projectile or foreign body. 12]. R.G. an individual treatment plan has to be established. K. are available. In more than 50% of the cases we had combined soft tissue and hard tissue injuries.M. D. W.S. 13]. and. alveolar nerve Soft tissue infection (floor of mouth) Soft tissue infection (cheek) Soft tissue infection (cheek) Soft tissue infection (orbit) Soft tissue infection (orbit) Soft tissue infection (orbit) Soft tissue infection (orbit) Major bleeding (A. The number of soft tissue injuries alone appears high. considering the intricate anatomy of the maxillofacial region. There are few case reports and not much data about the outcome of those cases.) Major bleeding (A. the accurate reproduction of a position in soft tissues is difficult.) Major bleeding(A. O. which were introduced a few years ago [11. In the literature the removal of projectiles is recommended [4] in some cases.C. Although ultrasound is not invasive and does not expose the patient to radiation. conventional radiographs. H. in exceptional cases some authors leave a projectile in situ [10. although there are some limitations for soft tissue imaging [6. A. 17. In the case of conventional skull radiographs. alternative techniques like ultrasound guided removal of projectiles as well as a mobile dental X-ray device for the acquisition of conventional radiographs in two planes with reference markers attached to the surgical site are described in the literature [15.H. We used cone-beam CT to reproduce the new position of spontaneously dislocated projectiles inside a sinus or to evaluate the immediate outcome of treated bony fractures. surgical removal of projectiles with and without appropriate use of a navigation system of radiological examinations are possible and described in the literature. P.P. – B. Similar to soft tissue repair. To replicate the new position of a projectile within the soft tissue or inside a sinus. temporalis) Not navigated Postoperative Fig. the objective to achieve minimally invasive surgical access. however. Soft tissue infection – (cheek) Soft tissue infection(chin) – • Sometimes projectiles tend to migrate within the soft tissue from the site of the entry. 8. because the projectile is not adjacent to a definite anatomical landmark.M. These findings were similar to those reported earlier in the literature [9. 23].R. the presence of multiple foreign bodies.and postoperative complications in detail Patient Complication Navigated Pre. O.) Major bleeding (A.F. However. H. Moreover. computed tomography (CT scans) and cone-beam CT. 16.and intraoperative D. K.T.

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