TRAUMA AND DAMAGE CONTROL SURGERY
C. Damage control surgery in moribund patient
The aim of damge control in moribund that is physiologically exhausted patient is to stop patient from entering into the lethal triad of acidoses, coagulopathy and hypothermia.
These are the patients who are near or into the lethal triad and therefore prolonged surgery will not be tolerated by them.
Patient selection criteria and 5 phases of damage control surgery are given below:
Physiological factors y Hypothermia y Profound hypotension y Acidoses
y Coagulopathy
y Prolonged surgery needed for definitive repair > 90 minutes
Complex injuries y Multiple trauma injuries = penetrating or blunt y Combined vascular and visceral injuries
y Multiple body cavities injury with competing management issues
Other considerations y Planned resurgery
y Injuries to be managed by nonoperative measures (embolisation, etc.)
y Variable physiology (adults, athletes, females)
y Phase 1: Involves control of hemorrhage and contamination. In this phase vessel injuries are just to be packed and not repaired (difference from damage control in field hospital) y Phase 2: Involves resuscitation in ICU
y Phase 3: Involves definitive surgery with points as shown below – Inspection/identification of all the injuries
– Control of all bleeding points – Careful removal of all previous packs
– Definitive gastrointestinal and vascular repairs – Thorough abdominal wash
– Radiography to rule out retained packs – Drains to be inserted if required – Feeding tubes if required
– Stomas and tube enterostomies should now be avoided
– Consideration for temporary or permanant abdominal wall closure.
y Phase 4: Involves planned ventral hernia if closure causes peak airway pressure to rise
>10 cm H2O
y Phase 5: Involves abdominal closure.
Q55. Classify faciomaxillary trauma and write a note on Le Fort fractures.
Write a note on mandible fractures.
Write a note on maxillary fractures.
Ans. Faciomaxillary trauma include the following
1. Orbit fracture y Superior orbital fissure syndrome—3,4,6 cranial nerves involved y Orbital apex syndrome—2,3,4,6 cranial nerves involved
y Most common site—Floor > medial wall
y Indications of surgery include enophthalmos> 2mm, fracture of
>50% of orbital floor, extraocular muscle entrapment, diplopia on primary or inferior gaze
y Access—transconjunctival/subciliary or lower blepharoplasty incision 2. Zygomatico-
maxillary complex fracture
y Zygomatic arch, lateral orbital wall, zygomaticofrontal and zygomaticomaxillary involved
y Access—coronal incision or upper eyelid incision for zygomaticofrontal and lateral orbital
y Access for orbital floor—tarsal/tarsoconjunctival incision
y Access for zygomaticomaxillary—maxillary gingivobuccal sulcus incision 3. Naso-orbito-
ethmoid fracture Plating or wiring all bones with or without primary bone grafting to be done
4. Frontal sinus
fracture y Only anterior table involved and displaced—ORIF
y Posterior table involved/CSF leak—ORIF for anterior table and for posterior table, remove posterior table bone, burr mucosa, obliterate Nasolacrimal duct, primary bone graft for posterior table and flap coverage of cavity
5. Nose fracture y Incise septal hematoma and give antibiotics y Closed reduction
y Reconstruction—nasolabial flaps and /or composite skin grafts can be used
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6. Ear defects y Small helical defects can be closed primarily
y Large defects—Antia Buch chondrocutaneous advancement flap 7. Lip defects and
reconstruction y Upper lip
− < 1/3 defect—primary closure
− 1/3 to 2/3 defect—abbe flap (noncommisural) estlender flap (commisural), reverse karapandzic flap (midline), perialar crescentic advancement flap
− > 2/3 defect—Burrow-Dieffenbach flap y Lower lip
− < 1/3 defect—primary closure
− 1/3 to 2/3 defect—abbe flap (noncommisural) estlender flap (commisural), karapandzic flap (midline)
− >2/3 defect—Gillies fan flap, Webster-Bernard repair, radial forearm free flap.
8. Eyelid
reconstruction y Upper eyelid
− <25% defect—primary closure
− 25-50%—lateral canthotomy and cantholysis with advancement flap
− >50%—cutler beard full thickness flap or modified Hughes tarsoconjunctival flap
y Lower eyelid
Similar to upper eyelid by primary closure, lateral release and advancement, partial thickness or full thickness grafts for anterior lamella
Fasanella-Servat procedure for ptosis 9. Maxilla (Le fort)
fracture Given by Le fort in 1911 which he described by looking at the pattern of skulls that he threw on ground from the terrace of a building
y Type 1—seperates alveolus from the rest of the facial skeleton Fracture line runs from inferior pterygoid plates, nasal pyriform
aperture and maxillary sinus
y Type 2—also called pyramidal fracture
Fracture line runs through middle of pterygoid plates and maxillary antrum, orbit, bridge of nose, ethmoids, with or without cribriform plate and infraorbital foramen
y Type 3—separates the facial skeleton from the base of the skull Fracture line runs through nasal bridge, septum, ethmoids, orbit, fronto-
maxillary suture and high through maxillary sinus and pterygoid plates.
Approach
y Ideal time for surgery—within 7 to 10 days after the original injury y M.C. indication for early intervention—restoration of the functional
integrity y Incisions
− Bicoronal—nasal root, frontozygomatic, orbital rim
− Lower eyelid blepharoplasty incision—orbital blowout fracture, infraor- bital rim fracture treated with bone grafts, titanium mesh or alloplasts
− Gingivobuccal maxillary sulcus incision—maxillary fractures y Preserve dental occlusion with the help of arch bars/Intermaxillary
fixation screws/eyelet wires/maxillofacial fixation system with titanium fixtures. This system do not require 6 weeks immobilization
Maxilla reconstruction y Principles
− Oronasal closure Contd...
Contd...
− Velopharyngeal competence
− Dental rehabilitation
− Height of cheeks
− Height of eye globes
y Small defects can be closed with obturators (malleable materials) y Large defects require flap reconstruction using deep circumflex
iliac artery flap or vascularised muscle (rectus/latissimus) with nonvcascularised bone graft
y Skin grafts with nasopharyngeal tube used for nasal passages to reconstruct and at the same time prevent blockage of the airways.
10. Mandible fracture and reconstruction
Most common site—neck of condyle
fracture or defect can be marginal (continuity of angle to symphyses is intact) or segmental (continuity is broken)
Anterior defect is defect anterior to mental foramen whereas lateral defect is defect lateral to mental foramen.
When segmental anterior deformity is not reconstructed it results in andy gump deformity and when lateral segmental defect is not reconstructed it causes dental malocclusion
HCL classification of mandibular defects (Urken et al) H—lateral defects of any length including condyle C—as above but condyle not included
L—central segment (canine to canine) Angle classification of malocclusion
1— normal alignment between mesial first maxillary molar and mandibular first molar
2—anterior displacement of maxillary first molar 3—posterior displacement of maxillary first molar
Guardsman fracture: Fracture of symphyses or parasymphyses on a direct blow to the chin point with unilateral or bilateral condylar fracture due to indirect energy transfer
Indications of ORIF: All bicondylar fracture or unicondylar displaced fracture
Technique of mandibular plating: AO/ASIF—rigid fixation or Champy- less rigid and functionally stable fixation.
Options in reconstruction of defects
y No bony reconstruction—soft tissue closure or interposition / alloplastic material (titanium or stainless steel)/local flaps
y Bony reconstruction—vascularized muscle with nonvascularized bone/
costochondral graft for TM joint/free bone graft
y Vascularised bone—pedicled or free (fibula/scapula/DCIA)
y Distraction histiogenesis (phases of osteotomies f/b latency f/b distraction at 1 mm/day f/b consolidation) can cover defects up to 6.5 cm
y Sequence of reconstruction includes distraction histiogenesis f/b TMJ reconstructions f/b dental implants
11. Cheek reconstruction of trauma defects
y Pectoralis major myocutaneous flap (acromiothoracic artery) y Deltopectoral flap (perforators of internal mammary artery) y Radial artery forearm free flap
y Temporoparietal forehead flap (anterior branch of superficial temporal artery)
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