A. Primary Surgical Treatment.
I. General Considerations.
1. A correlated plan of treatment, if carried out from the time the wound is incurred until definitive treatment is available, will greatly shorten the period of disability of patients with face and jaw injuries, and a larger number will be restored to approximately normal function and appearance than if haphazard methods are followed. Certain things should be done and others should not be done. Hence, attention to these points will save many lives and facilitate later treatment.
2. The use of local and systemic chemotherapy is indicated as for wounds of other parts of the body. This is particularly important in the treatment of massive wounds involving the floor of the mouth and those associated with compound fractures.
3. Primary care, points demanding special attention.
a. Control of hemorrhage.
b. Provision of adequate respiratory airway.
c. Temporary approximate reduction and fixation ofmaxillofacial fracturesand adjustment of parts to anatomical position. (Relief of pain, treatment ofshock, and other emergency measures as indicated.)
d. Early evacuation to a hospital for definitive treatment.
II. Specific Considerations.
1. Control of hemorrhage.
a. Control moderate hemorrhage by pressure from gauze compressand bandage.
b. Hemorrhage not controlled by pack and pressure will requireclamps andligature of the bleeding vessels. In case ligature is not available and clampis left on, it should be included in the bandage and marked.
c. In severe hemorrhage, life may be saved by application of digital pressureto a bleeding vessel at a control point in its course, until a clamp andligature can be applied.
d. DO NOT increase respiratory difficulty by the application of gauzecompress and bandage. Bandages should not create backward pressure ortraction distally on fractures of the mandible.
2. Provision of adequate respiratory airway.
a. Clear mouth and throat of tooth fragments, detached bone fragments, brokenor dislodged dentures, and all foreign matter.
b. Insufficient respiratory airway can be improved by the insertion of arubber tube through the nose or mouth to the nasopharynx.
c. Critical cases may require intra-tracheal tube.
d. Tracheotomy should be done promptly if more simple measures fail toprovide an adequate airway. In some cases of massive injury about the jaw andpharynx, tracheotomy will be necessary as an emergency life saving measure.
e. In case of collapse of pharynx and floor of the mouth, or loss of controlof the tongue, an airway can be maintained by holding the tongue forward. Thiscan be accomplished by passing a suture through the tip for holding itforward. (In extreme emergency cases safety pins have been used to transfix the tip of the tongue.) Fractures of the superiormaxillae frequently displace the loose structures downward and backward and definitely interferewith respiration. Bilateral comminuted fractures of the posterior part of the
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mandible may cause the chin segment to drop downward and backward, likewisecausing respiratory interference. In either case, the front of the jaw may beheld forward by a simple emergency splint.
(1) Material
Wooden tongue depressors, 4
Adhesive tape.
Bandage, 2-inch.
Ligature wire.(2) Construction
Two tongue depressors are placed end to end and are held by two othersoverlapping them in the middle, all being bound together with adhesive tape.
(3) Application
(a) This unit is secured vertically in the frontal region with a circularbandage so that the lower end is projected in front of the mouth. The upper endis attached to the bandage in the occipital region with a piece of tape.
(b) A wire ligature is attached to the lower teeth or passed around the chinsegment of the mandible, and the ends of the wire fastened to the lower end ofthe tongue depressor piece, either directly or with a rubber band.
(c) The spring of the tongue depressor piece or elastic traction effectivelykeeps the anterior segment of the mandible forward. Likewise in cases ofbackward displacement of the maxillae, forward traction can be obtained byattachment of the upper teeth to the apparatus.
3. Temporary approximate reduction and fixation of maxillo-facialfractures and adjustment of displaced parts to anatomical position.
a. Institute adequate measures for relief of pain andprevention of shock.Morphine should be administered cautiously to patients with respiratorydifficulty and is contra-indicated for patients with associated cranialinjuries.
b. Cleanse wound superficially, removing tooth fragments, detached boneparticles and foreign matter.
c. Displaced parts should be gently adjusted to anatomical position and gauzecompress and bandage applied. Avoid collapsing bone segments and preventbackward traction on the mandible.
d. Maxillary fractures and fractures of the adjacent facial bones should be gently supported by stable bandaging. In primary treatment, this stabilization can be improved by the application of gauze compresses and bandages used to control hemorrhage. It is essential to aid at re-establishing the former occlusion of the teeth, therefore all bandages applied should be supportive in this direction. Wire ligatures and suture material, if available, can be applied to the teeth of the same jaw across the line of fracture, to assist in stabilization of parts during evacuation. Multiple loop wiring, with intermaxillary elastic traction for reduction and stabilization of certain fractures, should be accomplished as early as time and facilities permit. Rigid intermaxillary fixation with wire is definitely contra-indicated in primary treatment for any case that might become nauseated or develop respiratory interference during evacuation. Edentulous cases require bandages that gently support the parts and avoid the tendency to collapse the segments. Dentures should be located, if possible, for use with adjustment and splinting of alveolar parts. These should always be transferred with the patient (even if broken).
e. Stabilization of parts is essential to avoid recurrent hemorrhage, reduce pain and prevent shock.
f. A stimulating dose of tetanus toxoid is indicated as for wounds of other parts of the body.
4. Evacuate patients to a hospital or station where definitive treatment can be provided early.
a. Ambulant or semi-ambulant patients with oral or pharyngeal wounds should travel sitting up, if possible.
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* * * * * * *b. Litter patients should be placed in a comfortable positionand prone (face down) so that there is no possibility of interference withrespiratory airway or aspiration of fluids.
B. Definitive Surgical Treatment.
I. General Considerations.
1. Superficial wounds are classified as those wounds of theface in which there is no evidence of fracture of facial bones, or deeppenetration. These wounds, when seen early, may be closed by primary suturing, providedthey are relatively clean and can be thoroughly cleansed and carefully debrided.Severe maxillofacial wounds with loss of tissue, especially those resulting fromgunshot, should not be closed by primary suturing. Specialized care should beinstituted as early as personnel, time and facilities permit.
2. Anesthesia is seldom required for the initial care ofmaxillofacial injuries before evacuation to an installation where definitivesurgical treatment can be accomplished. When an anesthetic is indicated, firstconsideration should be given to regional infiltration or nerve block anesthesiafor surgical treatment of severe traumatic lesions about the face. Generalanesthesia may be necessary if trauma involves structures in the nose, mouth orpharynx. Maintenance of an airway and prevention of seepage of blood into thetrachea is essential. The use of Pentothal [sodium] is hazardous and iscontra-indicated in presence of shock. Inhalation anesthesia is indicated.Introduction of an endotracheal tube, either through the mouth or nose, asconditions dictate, is highly desirable. Maintenance of Trendelenburg position(10?) will protect against seepage into the lung by promoting drainage of bloodand secretions into the pharynx where they can easily be removed by suction.Insertion of wet packs into the pharynx is also indicated to establish a closedsystem. If extensive trauma within the mouth or pharynx is likely to be followedby edema or emphysema, it may be necessary to establish a tracheal stoma priorto surgical treatment of the primary lesion, and to use this avenue of approachfor administration of the anesthetic by inhalation and subsequently foraspiration of excess secretions.
II. Specific Considerations.
1. Reduction and fixation of fractures and adjustment ofparts to anatomical position.
a. Secure consultation and aid of dental surgeon ifavailable.
b. Do not manipulate fractured fragments ofmaxillae in thepresence of fractures of the base of the skull and accompanying injury ofthe brain until drainage of fluid has ceased and patient's conditionapproximates normal.
c. Final control of hemorrhage. Use small hemostats and fineligatures. Ligate locally and not in course of the vessel and maintain maximumblood supply to the parts.
d. The wound should be cleansed thoroughly under the bestsurgical conditions. Remove all tooth fragments, foreign matter, detachedparticles of bone and dislodged teeth in line of fracture, since these areelements that invite infection. Do conservative debridement of soft tissues.Excise only tissue that is completely devitalized and tissue which obviously hasno chance of survival. Protect nerves, vessels, ducts and glands. The use ofsmall cutting needles and fine sutures placed near approximating skin edges willaid in prevention of suture scars. Skin sutures should be removed early.
e. Bone particles that still possessperiosteal attachment should never be removed, since these small vitalattachments may make all the difference between consolidation and new boneformation with restored function, and collapsed fragments with the attendantcomplications; even comminuted viable bone should be saved.
f. In cases of massive loss of substance, adjust soft tissueand restore torn flaps to normal position. Suture mucous membrane to skin edgesto cover raw surfaces and to preserve skin and mucous membrane. Avoid closuresunder tension that produce overlapping of fractured ends of bone or collapse ofbone fragments. Provide adequate dependent drainage to deep penetrating wounds,and especially those communicating with the mouth. Immediate suture is onlyadvisable in superficial wounds and wounds that can receive proper care within afew hours after injury.
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RETURN TO TABLE OF CONTENTSg. Fractures of maxillae and mandible.
(1) Complete roentgenographic studies should be an integralpart of definitive treatment.
(2) Aim at re-establishing the former occlusal relationshipof the teeth, and ultimate restoration of dental function. Collapse of bonesegments should be avoided in cases with loss of structure.
(4) The use of labial arch bars or wiring of the teeth ofthe same jaw across the line of fracture may be indicated for stabilizationduring evacuation.
(5) Rigid intermaxillary fixation of the lower teeth to theupper should not be used prior to unattended travel. Intermaxillaryelastic traction may be used safely for this stabilization since the mouth canbe opened in case of nausea and the elastic bands easily removed or tensionregulated as indicated.
(6) Immobilization of fractures can beaccomplished by theapplication of intramaxillary multiple loop wires and intermaxillary elastics,for reduction and fixation, when sufficient teeth remain in each jaw. Theapplication of a vertical circular bandage with mild buccal elastic traction maybe indicated for auxiliary support of maxillary fractures. (Thisbandage, made of plastic material, will eliminate the collapsing tendency ofordinary bandage.)
(7) Sectional dental splints of proper design andconstruction may be used to advantage in the treatment of complicated casesfor immobilization when limited function is desirable.
(8) Edentulous fractures require the skillful application ofsupporting bandages to maintain the parts in proper position, without causingcollapse of segments or interference with airway. Dentures are particularlyimportant as they can often be used in connection with supporting bandages orcircumferential wiring.
(9) Another method of reduction and retention of edentulouscases, or those with displaced edentulous fragments, is afforded by theapplication of the extra-oral skeletal pin and bar fracture appliance.
2. Every effort should be made to provide trained personnelfor the care of maxillofacial injuries throughout the combat area. Adequatelife-saving measures and early treatment are necessary to insure the casualtiesgetting to the hospitals of the next echelon for more definitive treatment. Theexecution of a well-correlated plan of treatment throughout will not only savelife but result in many casualties being returned to duty after a minimumperiod of hospitalization. End results are of great concern and usually said tobe directly proportionate to the nature and character of the early treatmentreceived. Patients with maxillofacial injuries, requiring extended care andreconstructive surgery, should be transferred to the Zone of Interior when thetreatment has progressed to such a stage that evacuation can be safelyaccomplished.
