[Main theme: multiple trauma--III. Interdisciplinary treatment of facial injuries. Facial injuries in multiple injured patients. Otorhinolaryngological aspects].
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As otolaryngologists become more involved with maxillofacial trauma, we are encountering an increasing number of athletic injuries. Ice hockey accounts for a large number of these facial injuries. The fast moving and random nature of the game, frequent body and equipment contact and lack of protective devices, predisposes the hockey player to facial injury. Because of the roughly tenfold increase in hockey participation over the last decade, the problem of facial injury prevention has become a significant public health problem in North America. Review of the medical literature shows a paucity of interest in the subject of facial injury prevention in hockey. Several articles have dealt with ocular injury, while other articles have dealt with the general subject of hockey injury with only scant attention paid to the facial area. A retrospective study was carried out to more clearly define the scope of the facial injury problem. Four levels of hockey play were examined. Individuals from the youngest and most inexperienced to seasoned professionals were studied. An individually completed questionnaire was received from players in each group. It is the purpose of this paper to indicate the rates of injury for the various types of facial trauma, present their mechanisms of occurrence and discuss means of preventing facial injury in hockey players.
Most facial injuries are not dire emergencies, except in the case of airway obstruction and in unrecognized, prolonged bleeding or oozing from facial wounds. Yet one must keep in mind the psychologic impact that facial injuries may have upon the patient and his family.
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Over a period of one year 20 549 new patients attended an accident and emergency department. Of these patients, 15 555 were victims of accidents, including 875 who had sustained facial injuries. This latter group comprised 609 patients with soft tissue trauma and 266 with skeletal injury. The frequency, aetiology, age and sex distribution of the facial injuries were analysed and compared with other published statistical surveys of facial injury. It is concluded that facial injuries constitute a significant proportion of the work of a civilian accident unit and that any accident service must have adequate facilities for the management of these injuries.
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I report 1,110 patients with lower-third facial injuries isolated from 1,608 patients with different types of facial injuries. Mixed injuries (bone and soft tissue) were most common (72%; n = 805). The most common site of fracture was the body of the mandible (26.12%; n = 290). One hundred sixty-three patients underwent soft-tissue and bony reconstruction with a local soft-tissue flap or an iliac bone graft, or both. Three procedures failed because of gingival tearing. Other treatments ranged from conservative treatment to different types of closed or open reduction. Postinjury and postsurgery complications were many and involved soft tissue, nerves, tongue, and bones. The follow-up period ranged from 3 months to 3 years.
Accidents caused by kickback from chain saws produce facial injuries with consistent features. These features include oblique, destructive, ragged lacerations of the left side of the face. Although eyelid damage may be severe, damage to the globe itself is minimal. An analysis of 10 such accidents revealed this consistent pattern. Of this group, eight injuries were left-sided and six involved mainly the eyelid and adjacent structures. Only one patient was left with permanent damage to the globe and with slightly impaired (20/60) vision. The upper lid was always more severely damaged than the lower. The author discusses the merits and disadvantages of protective devices for both operator and machine.
Bicycle accidents in adults are common and concern frequently injuries to head and face. 150 of totally 216 patients with cycle accidents in a six month' prospective study at the Basel University Hospital showed face and head trauma. 85 severe facial injuries treated operatively by the Clinic for Reconstructive Surgery between 1985 and 1989 are analysed in detail. These facial injuries are rarely life threatening and normally the postoperative outcome is good. Nevertheless, usual bicycle helmets cannot avoid facial trauma. Therefore traffic educational programs are the most important prophylactic efforts. Technical progress and improvement of the bicycles ask for better trained cyclists. Further more, the importance of really respecting the traffic rules as well as the construction of separate cycle routes is stressed.
Damage to facial tissue caused by an ophthalmic frame when there is impact to the face was studied by means of a paraffin-covered mannequin head. Under mild conditions of impact it was easily observed that metal frames and metal components do more tissue damage than is done by a zylframe. A series of the commonly dispensed frames was compared for facial injury potential caused by impact to the face.
In spite of a certain reduction in their numbers, facial injuries still raise frequent problems for general surgeons. Car accidents are now less commonly responsible than motorcycle accidents. In the most complex cases, one may find lesions of the soft parts and bony lesions in association. The wounds should be examined carefully, all foreign bodies removed and should only be sutured if one is certain tht the subjacent structures are undamaged, e.g. facial bony canals are often damaged in vertical wounds of the cheek situated behind the anterior border of the masseter muscle. As far as bony lesions are concerned, they rarely give rise to typical breakdowns of the suture lines described by Lefort, but more commonly cause true dislocations which are impossible to describe. Fractures are often undiagnosed owing to oedema which masks them, e.g. those of the malar bone and of the orbit and even those of the nose. This failure to diagnose them is serious for, at a later stage, surgical correction is more difficult and the prejudice is then not only esthetic but also functional, e.g. causing diplopia. Clinical examination of a patient with trauma of the face includes a series of simple gestures which a general surgeion should carry out in order to avoid failure to diagnose such lesions. Although he may not treat them all, he sould recognise them and decide which have priority in the treatment of multiple injuries. Careful inspection and palpation usually permit one to detect bony lesions which XRays then demonstrate only by careful choice of appropriate views.
A case of maxillo-facial injuries in a patient with severe haemophilia is described. Problems of treatment and management are discussed from both surgical and haematological points of view.
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