TY - JOUR
AU - DuBose, Joseph, J
AB - Abstract Introduction Facial fractures sustained in combat are generally unrepresentative of those commonly experienced in civilian practice. In the US military, acute trauma patient care is guided by the Joint Trauma System Clinical Practice Guidelines but currently none exists for facial trauma. Materials and methods All casualties that underwent surgery to facial fractures between January 01, 2016 and September 15, 2019 at a US deployed Military Treatment Facility in Afghanistan were identified using the operating room database. Surgical operative records and outpatient records for local Afghan nationals returning for follow-up were reviewed to determine outcomes. Results 55 casualties underwent treatment of facial fractures; these were predominantly from explosive devices (27/55, 49%). About 46/55 (84%) were local nationals, of which 32 (70%) were followed up. Length of follow-up ranged between 1 and 25 months. About 36/93 (39%) of all planned procedures developed complications, with the highest being from ORIF mandible (18/23, 78%). About 8/23 (35%) casualties undergoing ORIF mandible developed osteomyelitis, of which 5 developed nonunion. Complications were equally likely to occur in those procedures for “battlefield type” events such as explosive devices and gunshot wounds (31/68, 46%) as those from “civilian type” events such as falls or motor vehicle collisions (5/11, 45%). Conclusions Complications Rates from facial fractures were higher than that reported in civilian trauma. This likely reflects factors such as energy deposition, bacterial load, and time to treatment. Load sharing osteosynthesis should be the default modality for fracture fixation. External fixation should be considered in particular for complex high-energy or infected mandible fractures where follow-up is possible. INTRODUCTION In recent military conflicts, the face is injured in 10–26% of casualties,1–3 with one review finding facial fractures in 28% of evacuated United States (US) service personnel.4 Conflicts involving greater proportions of explosive devices generally cause more facial injuries than those in which gunshot wounds (GSWs) have predominated.5 The use of combat helmets and ballistic eyewear by coalition forces has reduced facial injury incidence, and this may improve further with the increased adoption of visors in certain tactical scenarios.6 The lack of ballistic protection means that local nationals, in particular civilians, have higher proportions of facial injuries than military service personnel.7 Facial fractures sustained in combat are generally unrepresentative of those commonly experienced in civilian practice.8 Clinicians working in Level 1 Trauma centers may treat casualties with GSWs, but with the rare exceptions of terrorist events, those injured by blast events are unusual.9 High-velocity GSWs and blast injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, bony comminution with bone and ballistic fragment sequestrum.8 Interpreting the optimal manner to treat such injuries can be problematic due to a lack of international consensus on the optimal management of such injuries. The literature on facial fractures treated in recent conflicts has been dominated by epidemiological data using the Joint Trauma Registries.1,3,10,11 Multiple studies have demonstrated the outcomes of US and United Kingdom (UK) casualties treated in the home nation.8,12–14 Data published from deployed hospitals have demonstrated differing treatment approaches,15–22 with the most recent published clinical activity up to 2007.15,16 Some authors have advocated the use of maxillary-mandibular fixation (MMF) and external fixation for combat maxillofacial injuries.19–22 This was based upon their experience that internal fixation of facial fractures was often not appropriate for high velocity and contaminated wounds.23 If required, casualties underwent internal fixation after 3–5 days, with definitive reconstruction delayed to the home country for coalition soldiers. Other authors have advocated the greater use of early internal fixation of mandible fractures prior to the evacuation of coalition forces,15,17,18,24,25 primarily it appears to reduce the requirement for surgical tracheostomy during evacuation.3 Although this appears to have increased the rates of internal fixation in some locations,3 it did not become widely accepted for coalition forces, probably due to the risks of increased infection.26,27 Unpublished opinion is that it become more common for host nation forces to be treated immediately by internal fixation whatever the mechanism of injury since those early papers published 2007,17 although exact numbers have not been described. US and UK military doctrine supports deploying and organizing health services at levels with progressive capabilities referred to as the four roles of care (Roles 1–4), each with different Military Treatment Facilities (MTFs).28 Role 3 hospitals are the first capability with subspecialty surgical care for head and neck trauma. Since the start of Operation Resolute Support on January 1, 2015, facial injuries have been primarily managed by US Air Force otolaryngology (ENT) surgeons,29 with the assistance of UK Oral and Maxillofacial surgeons since March 2019. The rules of engagement allow Role 3 MTFs to provide medical support to all US and Coalition forces, Afghan military or civilians working with US forces, and in some instances Afghan civilians.30 Further management of facial trauma in US military personnel occurred following evacuation to Landstuhl Regional Medical Centre (LRMC) in Germany (Role 4) and to homeland US.31,32 A lack of international consensus exists regarding the management of facial injuries in the deployed setting, in particular the use of external versus internal fixation for facial fractures. It has recently been highlighted that there are currently no Joint Trauma System (JTS) Clinical Practice Guidelines (CPGs) for facial trauma.7 In the US military, acute trauma patient care is guided by the JTS CPGs.33 Currently, no CPG exists for facial trauma. The aim of this analysis was therefore to determine the types, causes, and outcomes of facial fractures treated at a US Role 3 MTF to lend evidence toward the development a facial fracture CPG and generate international consensus in their management. MATERIALS AND METHODS All casualties that underwent surgery to treat facial fractures between January 01, 2016 and September 15, 2019 were identified using the operating room (OR) database. Hospital numbers and patient names were cross referenced with surgical operative records derived from the hospital Theater Medical Information Program Composite Health Care System Cache (TC2). Emergency Department (ED) records were used to identify discrepancies between temporary patient identifiers and casualties treated under local anesthesia in the ED alone. For local nationals only, outpatient records were reviewed using the Armed Forced Health Longitudinal Technology Application—Theater system to determine complications and time to last follow-up. Removal of archbars was not counted as a procedure in terms of determining complications. Wound breakdown was not counted as a complication unless an infection that at least required antibiotics developed. RESULTS During this period, records identified 55 casualties that underwent treatment of facial fractures (Online Table I). Battle injury predominated (45/55, 82%), followed by nonbattle injury (8/55, 18%), with the most common casualty cohort treated being local nationals (46/55, 84%) followed by US Military (4/55, 7%). Prehospital cricothyroidotomies were performed on 4 casualties with facial fractures. Table I Cause of Patient Injury. Explosive Devices Included IED, Grenade, and Mortar. MVC = Motor Vehicle Collision Injury . Cause . Penetrating . Blunt . All . Battle Explosive device 25 2 27 GSW 14 0 14 MVC 0 4 4 Nonbattle Fall 0 5 5 MVC 0 2 2 GSW 1 0 1 Sports 0 2 2 All 40 15 55 Injury . Cause . Penetrating . Blunt . All . Battle Explosive device 25 2 27 GSW 14 0 14 MVC 0 4 4 Nonbattle Fall 0 5 5 MVC 0 2 2 GSW 1 0 1 Sports 0 2 2 All 40 15 55 Open in new tab Table I Cause of Patient Injury. Explosive Devices Included IED, Grenade, and Mortar. MVC = Motor Vehicle Collision Injury . Cause . Penetrating . Blunt . All . Battle Explosive device 25 2 27 GSW 14 0 14 MVC 0 4 4 Nonbattle Fall 0 5 5 MVC 0 2 2 GSW 1 0 1 Sports 0 2 2 All 40 15 55 Injury . Cause . Penetrating . Blunt . All . Battle Explosive device 25 2 27 GSW 14 0 14 MVC 0 4 4 Nonbattle Fall 0 5 5 MVC 0 2 2 GSW 1 0 1 Sports 0 2 2 All 40 15 55 Open in new tab The most common cause of injury was explosive devices (27/55, 49%), which included improvised explosive devices (IEDs), grenades, and rockets (Table I). Mandible fractures were treated in 29 casualties, of which 23/29 (79%) were from penetrating injury (explosive devices or GSW), and 6/29 (21%) for blunt trauma (motor vehicle collisions or a fall). Of the 55 casualties with treated facial fractures, 125 fractures were identified and underwent 128 episodes in the OR (Online Table II). About 26/29 (90%) casualties with treated mandible fractures were local civilians. The remaining 3 casualties were three isolated mandible fractures in 2 US civilians (one treated by MMF and one by ORIF) and in one coalition military serviceperson (treated by an external fixator)—all of whom were evacuated to LRMC. Two casualties sustained isolated bilateral orbital floor fractures from explosive devices, with each casualty described being between 6 and 9 feet from the device at the time of injury, with injury attributable to the blast wave. Table II Procedure Performed and Incidence of Complications for Facial Fractures Treated in Local Nationals Description . Initial procedures . Planned follow-up procedures . Additional procedures for complications . Followed up . Complication of initial and planned procedures . Complications of initial and planned procedures (as % of those treated) . ORIF mandible + interoperative only MMF (excluding condyle) 19 0 13 19 14 74% ORIF + post- operative MMF mandible (excluding condyle) 4 4 2 3 4 50% External fixator for mandible fracture (excluding condyle) 0 0 1 1 0 0% MMF mandible condylar fracture 6 0 0 3 2 17% Orbital wall fracture repair (plate) 11 0 5 7 5 45% Cranialisation frontal sinus fracture 6 0 0 1 0 0% Fixation of dentoalveolar fracture treatment 3 0 2 3 2 66% Closed reduction nasal fracture 8 1 0 5 2 22% ORIF zygoma fracture 7 0 0 4 2 29% ORIF or MMF maxilla fracture 4 0 1 3 2 50% Iliac crest bone graft to mandible fracture defect 4 0 2 2 2 50% Calvarial bone graft to orbital fracture 2 0 1 1 1 50% All 74 5 26 53 36 46% Description . Initial procedures . Planned follow-up procedures . Additional procedures for complications . Followed up . Complication of initial and planned procedures . Complications of initial and planned procedures (as % of those treated) . ORIF mandible + interoperative only MMF (excluding condyle) 19 0 13 19 14 74% ORIF + post- operative MMF mandible (excluding condyle) 4 4 2 3 4 50% External fixator for mandible fracture (excluding condyle) 0 0 1 1 0 0% MMF mandible condylar fracture 6 0 0 3 2 17% Orbital wall fracture repair (plate) 11 0 5 7 5 45% Cranialisation frontal sinus fracture 6 0 0 1 0 0% Fixation of dentoalveolar fracture treatment 3 0 2 3 2 66% Closed reduction nasal fracture 8 1 0 5 2 22% ORIF zygoma fracture 7 0 0 4 2 29% ORIF or MMF maxilla fracture 4 0 1 3 2 50% Iliac crest bone graft to mandible fracture defect 4 0 2 2 2 50% Calvarial bone graft to orbital fracture 2 0 1 1 1 50% All 74 5 26 53 36 46% Open in new tab Table II Procedure Performed and Incidence of Complications for Facial Fractures Treated in Local Nationals Description . Initial procedures . Planned follow-up procedures . Additional procedures for complications . Followed up . Complication of initial and planned procedures . Complications of initial and planned procedures (as % of those treated) . ORIF mandible + interoperative only MMF (excluding condyle) 19 0 13 19 14 74% ORIF + post- operative MMF mandible (excluding condyle) 4 4 2 3 4 50% External fixator for mandible fracture (excluding condyle) 0 0 1 1 0 0% MMF mandible condylar fracture 6 0 0 3 2 17% Orbital wall fracture repair (plate) 11 0 5 7 5 45% Cranialisation frontal sinus fracture 6 0 0 1 0 0% Fixation of dentoalveolar fracture treatment 3 0 2 3 2 66% Closed reduction nasal fracture 8 1 0 5 2 22% ORIF zygoma fracture 7 0 0 4 2 29% ORIF or MMF maxilla fracture 4 0 1 3 2 50% Iliac crest bone graft to mandible fracture defect 4 0 2 2 2 50% Calvarial bone graft to orbital fracture 2 0 1 1 1 50% All 74 5 26 53 36 46% Description . Initial procedures . Planned follow-up procedures . Additional procedures for complications . Followed up . Complication of initial and planned procedures . Complications of initial and planned procedures (as % of those treated) . ORIF mandible + interoperative only MMF (excluding condyle) 19 0 13 19 14 74% ORIF + post- operative MMF mandible (excluding condyle) 4 4 2 3 4 50% External fixator for mandible fracture (excluding condyle) 0 0 1 1 0 0% MMF mandible condylar fracture 6 0 0 3 2 17% Orbital wall fracture repair (plate) 11 0 5 7 5 45% Cranialisation frontal sinus fracture 6 0 0 1 0 0% Fixation of dentoalveolar fracture treatment 3 0 2 3 2 66% Closed reduction nasal fracture 8 1 0 5 2 22% ORIF zygoma fracture 7 0 0 4 2 29% ORIF or MMF maxilla fracture 4 0 1 3 2 50% Iliac crest bone graft to mandible fracture defect 4 0 2 2 2 50% Calvarial bone graft to orbital fracture 2 0 1 1 1 50% All 74 5 26 53 36 46% Open in new tab When analysing local nationals alone, 46 casualties underwent 74 initial procedures and a further 5 planned follow-up procedures (Table II). About 45/46 (98%) casualties with treated fractures had preoperative scans, of which 43/46 (93%) had a formal report available, and 39/46 (85%) had the actual scan that could be analyzed. Postoperative scans were taken on 14/46 (30%) casualties with treated fractures, of which all were available for analysis. Operation notes were available for 45/46 casualties (98%) with treated facial fractures. About 32/46 (70%) patients with treated facial fractures were subsequently followed up. Of these, the number of appointments ranged from 1 to 6 (mean 1.8) and follow-up time ranged from 1 to 25 months (mean 6 months). Complications occurred in 23/46 (50%) of local nationals. Complications were similarly likely to occur in those injured by explosive devices and GSW (19/39, 49%) than those from MVC and falls (3/7, 43%). In terms of procedures, complications were recorded in 36/79 (46%) initial and planned follow-up procedures, requiring an additional 26 unplanned procedures (Table II). Five tracheotomies were performed for facial fractures (2 panfacial, 3 mandible); no recorded complications were reported from a tracheotomy. In terms of procedures, the incidence of complications was 31/68 (46%) for procedures performed on “battlefield” type injuries (explosive, GSW, Table III) compared with 5/11(45%) in those injuries’ representative of the civilian environment (MVC, fall, Table IV). The most common complication overall was infection requiring antibiotics (19/79, 20%). Overall, 19/27 (70%) casualties from ORIF mandible (noncondyle) fractures developed complications, which again was more common in battlefield-type injuries. About 8/27 (35%) ORIF mandible developed osteomyelitis (all GSW or explosions), of which 5 patients developed a nonunion. Infection was identified at the first postoperative visit in 17/19 (89%) mandible fractures that developed it. About 16/19 (84%) were discharged on oral antibiotics alone, with the remainder admitted acutely for repeat surgery. Of those 16 discharged on oral antibiotics, 10/16 (63%) subsequently required surgery when they attended on a further outpatient attendance. Table III Complications From Procedures Performed for Battlefield Type Injuries (GSW and Explosions) in Local Nationals. Individual Rows and Columns Are Not Cumulative as Treatment of a Single Fracture Might Result in More Than One Complication and Not All Complications Are Relevant Complication Type . ORIF Mandible (Excluding Condyle) . MMF Condyle . ORIF or MMF Maxilla or Zygoma . ORIF Orbit . Open or Closed Reduction Nose . Dentoalveolar Fracture Treatment . Frontal Sinus Fracture Cranialisation . Bone Graft Placement . All . Incorrect bone reduction causing deformity 4/23 (17%) 0/4 (0%) 1/9 (11%) 2/7 (29%) 2/3 (67%) 0/6 (0%) 9/52 (17%) Infection requiring antibiotics 9/23 (39%) 0/4 (0%) 2/9 (22%) 2/10 (20%) 1/7 (14%) 2/3 (67%) 0/6 (0%) 2/6 (33%) 18/68 (26%) Infection requiring subsequent OR episode for plate removal 5/23 (22%) 2/9 (22%) 0/10 (0%) 1/3 (33%) 0/6 (0%) 8/51 (16%) Infection requiring subsequent OR episode for graft removal 2/6 (33%) 2/6 (33%) Infection/mobility requiring subsequent OR episode for tooth removal 5/23 (22%) 0/9 (0%) 0/10 (0%) 2/3 (67%) 7/45 (16%) Malocclusion (including AOB) 4/23 (17%) 0/4 (0%) 2/9 (22%) 0/10 (0%) 0/7 (0%) 2/3 (67%) 8/56 (14%) Limited mouth opening (<25 mm) 7/23 (30%) 0/4 (0%) 0/11 (0%) 0/10 (0%) 0/7 (0%) 2/3 (67%) 9/58 (16%) Orbital plate malposition 3/10 (30%) 3/10 (30%) Any complication 16/23 (70%) 0/4 (0%) 3/9 (33%) 5/10 (50%) 2/7 (29%) 2/3 (67%) 0/6 (0%) 3/6 (33%) 31/68 (46%) Complication Type . ORIF Mandible (Excluding Condyle) . MMF Condyle . ORIF or MMF Maxilla or Zygoma . ORIF Orbit . Open or Closed Reduction Nose . Dentoalveolar Fracture Treatment . Frontal Sinus Fracture Cranialisation . Bone Graft Placement . All . Incorrect bone reduction causing deformity 4/23 (17%) 0/4 (0%) 1/9 (11%) 2/7 (29%) 2/3 (67%) 0/6 (0%) 9/52 (17%) Infection requiring antibiotics 9/23 (39%) 0/4 (0%) 2/9 (22%) 2/10 (20%) 1/7 (14%) 2/3 (67%) 0/6 (0%) 2/6 (33%) 18/68 (26%) Infection requiring subsequent OR episode for plate removal 5/23 (22%) 2/9 (22%) 0/10 (0%) 1/3 (33%) 0/6 (0%) 8/51 (16%) Infection requiring subsequent OR episode for graft removal 2/6 (33%) 2/6 (33%) Infection/mobility requiring subsequent OR episode for tooth removal 5/23 (22%) 0/9 (0%) 0/10 (0%) 2/3 (67%) 7/45 (16%) Malocclusion (including AOB) 4/23 (17%) 0/4 (0%) 2/9 (22%) 0/10 (0%) 0/7 (0%) 2/3 (67%) 8/56 (14%) Limited mouth opening (<25 mm) 7/23 (30%) 0/4 (0%) 0/11 (0%) 0/10 (0%) 0/7 (0%) 2/3 (67%) 9/58 (16%) Orbital plate malposition 3/10 (30%) 3/10 (30%) Any complication 16/23 (70%) 0/4 (0%) 3/9 (33%) 5/10 (50%) 2/7 (29%) 2/3 (67%) 0/6 (0%) 3/6 (33%) 31/68 (46%) Open in new tab Table III Complications From Procedures Performed for Battlefield Type Injuries (GSW and Explosions) in Local Nationals. Individual Rows and Columns Are Not Cumulative as Treatment of a Single Fracture Might Result in More Than One Complication and Not All Complications Are Relevant Complication Type . ORIF Mandible (Excluding Condyle) . MMF Condyle . ORIF or MMF Maxilla or Zygoma . ORIF Orbit . Open or Closed Reduction Nose . Dentoalveolar Fracture Treatment . Frontal Sinus Fracture Cranialisation . Bone Graft Placement . All . Incorrect bone reduction causing deformity 4/23 (17%) 0/4 (0%) 1/9 (11%) 2/7 (29%) 2/3 (67%) 0/6 (0%) 9/52 (17%) Infection requiring antibiotics 9/23 (39%) 0/4 (0%) 2/9 (22%) 2/10 (20%) 1/7 (14%) 2/3 (67%) 0/6 (0%) 2/6 (33%) 18/68 (26%) Infection requiring subsequent OR episode for plate removal 5/23 (22%) 2/9 (22%) 0/10 (0%) 1/3 (33%) 0/6 (0%) 8/51 (16%) Infection requiring subsequent OR episode for graft removal 2/6 (33%) 2/6 (33%) Infection/mobility requiring subsequent OR episode for tooth removal 5/23 (22%) 0/9 (0%) 0/10 (0%) 2/3 (67%) 7/45 (16%) Malocclusion (including AOB) 4/23 (17%) 0/4 (0%) 2/9 (22%) 0/10 (0%) 0/7 (0%) 2/3 (67%) 8/56 (14%) Limited mouth opening (<25 mm) 7/23 (30%) 0/4 (0%) 0/11 (0%) 0/10 (0%) 0/7 (0%) 2/3 (67%) 9/58 (16%) Orbital plate malposition 3/10 (30%) 3/10 (30%) Any complication 16/23 (70%) 0/4 (0%) 3/9 (33%) 5/10 (50%) 2/7 (29%) 2/3 (67%) 0/6 (0%) 3/6 (33%) 31/68 (46%) Complication Type . ORIF Mandible (Excluding Condyle) . MMF Condyle . ORIF or MMF Maxilla or Zygoma . ORIF Orbit . Open or Closed Reduction Nose . Dentoalveolar Fracture Treatment . Frontal Sinus Fracture Cranialisation . Bone Graft Placement . All . Incorrect bone reduction causing deformity 4/23 (17%) 0/4 (0%) 1/9 (11%) 2/7 (29%) 2/3 (67%) 0/6 (0%) 9/52 (17%) Infection requiring antibiotics 9/23 (39%) 0/4 (0%) 2/9 (22%) 2/10 (20%) 1/7 (14%) 2/3 (67%) 0/6 (0%) 2/6 (33%) 18/68 (26%) Infection requiring subsequent OR episode for plate removal 5/23 (22%) 2/9 (22%) 0/10 (0%) 1/3 (33%) 0/6 (0%) 8/51 (16%) Infection requiring subsequent OR episode for graft removal 2/6 (33%) 2/6 (33%) Infection/mobility requiring subsequent OR episode for tooth removal 5/23 (22%) 0/9 (0%) 0/10 (0%) 2/3 (67%) 7/45 (16%) Malocclusion (including AOB) 4/23 (17%) 0/4 (0%) 2/9 (22%) 0/10 (0%) 0/7 (0%) 2/3 (67%) 8/56 (14%) Limited mouth opening (<25 mm) 7/23 (30%) 0/4 (0%) 0/11 (0%) 0/10 (0%) 0/7 (0%) 2/3 (67%) 9/58 (16%) Orbital plate malposition 3/10 (30%) 3/10 (30%) Any complication 16/23 (70%) 0/4 (0%) 3/9 (33%) 5/10 (50%) 2/7 (29%) 2/3 (67%) 0/6 (0%) 3/6 (33%) 31/68 (46%) Open in new tab Table IV Complications From Procedures Performed for Civilian-Type Injuries (MVC and Fall) in Local Nationals. Individual Rows and Columns Are Not Cumulative as Treatment of a Single Fracture Might Result in More Than One Complication and Not All Complications Are Relevant Complication type . ORIF Mandible (Excluding Condyle) . MMF Condyle . ORIF or MMF Maxilla or Zygoma . ORIF Orbit . Closed Reduction Nose . All . Incorrect bone reduction causing deformity 0/4 (0%) 0/2 (0%) 1/2 (50%) 0/2 (0%) 1/8 (13%) Infection requiring antibiotics 1/4 (25%) 0/2 (0%) 0/2 (0%) 0/1 (0%) 0/2 (0%) 1/11 (9%) Infection requiring subsequent OR episode for plate removal 1/4 (25%) 0/2 (0%) 0/1 (0%) 1/7 (14%) Malocclusion (including AOB) 1/4 (25%) 2/2 (100%) 0/2 (0%) 3/18 (17%) Limited mouth opening (<25 mm) 0/4 (0%) 2/2 (100%) 0/2 (0%) 2/8 (25%) Orbital plate malposition 0/1 (0%) 0/1 (0%) Facial nerve weakness 1/4 (25%) 1/4 (25%) Any complication 2/4 (50%) 2/2 (100%) 1/2 (50%) 0/1 (0%) 0/2 (0%) 5/11 (45%) Complication type . ORIF Mandible (Excluding Condyle) . MMF Condyle . ORIF or MMF Maxilla or Zygoma . ORIF Orbit . Closed Reduction Nose . All . Incorrect bone reduction causing deformity 0/4 (0%) 0/2 (0%) 1/2 (50%) 0/2 (0%) 1/8 (13%) Infection requiring antibiotics 1/4 (25%) 0/2 (0%) 0/2 (0%) 0/1 (0%) 0/2 (0%) 1/11 (9%) Infection requiring subsequent OR episode for plate removal 1/4 (25%) 0/2 (0%) 0/1 (0%) 1/7 (14%) Malocclusion (including AOB) 1/4 (25%) 2/2 (100%) 0/2 (0%) 3/18 (17%) Limited mouth opening (<25 mm) 0/4 (0%) 2/2 (100%) 0/2 (0%) 2/8 (25%) Orbital plate malposition 0/1 (0%) 0/1 (0%) Facial nerve weakness 1/4 (25%) 1/4 (25%) Any complication 2/4 (50%) 2/2 (100%) 1/2 (50%) 0/1 (0%) 0/2 (0%) 5/11 (45%) Open in new tab Table IV Complications From Procedures Performed for Civilian-Type Injuries (MVC and Fall) in Local Nationals. Individual Rows and Columns Are Not Cumulative as Treatment of a Single Fracture Might Result in More Than One Complication and Not All Complications Are Relevant Complication type . ORIF Mandible (Excluding Condyle) . MMF Condyle . ORIF or MMF Maxilla or Zygoma . ORIF Orbit . Closed Reduction Nose . All . Incorrect bone reduction causing deformity 0/4 (0%) 0/2 (0%) 1/2 (50%) 0/2 (0%) 1/8 (13%) Infection requiring antibiotics 1/4 (25%) 0/2 (0%) 0/2 (0%) 0/1 (0%) 0/2 (0%) 1/11 (9%) Infection requiring subsequent OR episode for plate removal 1/4 (25%) 0/2 (0%) 0/1 (0%) 1/7 (14%) Malocclusion (including AOB) 1/4 (25%) 2/2 (100%) 0/2 (0%) 3/18 (17%) Limited mouth opening (<25 mm) 0/4 (0%) 2/2 (100%) 0/2 (0%) 2/8 (25%) Orbital plate malposition 0/1 (0%) 0/1 (0%) Facial nerve weakness 1/4 (25%) 1/4 (25%) Any complication 2/4 (50%) 2/2 (100%) 1/2 (50%) 0/1 (0%) 0/2 (0%) 5/11 (45%) Complication type . ORIF Mandible (Excluding Condyle) . MMF Condyle . ORIF or MMF Maxilla or Zygoma . ORIF Orbit . Closed Reduction Nose . All . Incorrect bone reduction causing deformity 0/4 (0%) 0/2 (0%) 1/2 (50%) 0/2 (0%) 1/8 (13%) Infection requiring antibiotics 1/4 (25%) 0/2 (0%) 0/2 (0%) 0/1 (0%) 0/2 (0%) 1/11 (9%) Infection requiring subsequent OR episode for plate removal 1/4 (25%) 0/2 (0%) 0/1 (0%) 1/7 (14%) Malocclusion (including AOB) 1/4 (25%) 2/2 (100%) 0/2 (0%) 3/18 (17%) Limited mouth opening (<25 mm) 0/4 (0%) 2/2 (100%) 0/2 (0%) 2/8 (25%) Orbital plate malposition 0/1 (0%) 0/1 (0%) Facial nerve weakness 1/4 (25%) 1/4 (25%) Any complication 2/4 (50%) 2/2 (100%) 1/2 (50%) 0/1 (0%) 0/2 (0%) 5/11 (45%) Open in new tab Of the 5 patients with residual limited mouth opening following mandible fracture not involving the condyle, all had MMF with wires or tight elastics which was left on at the end of the operation for at least 2 weeks and did not have an associated condyle fracture. In 2/6 (34%) casualties treated for zygoma fractures, the bone could not be reduced fully resulting in residual deformity. Both were blunt injuries with minimal comminution. Postoperative CT scans showed suboptimal reduction, but neither patient returned to the OR. Of the 5 initial procedures with complications from orbital surgery, 5 were orbital floor plates that were malpositioned that required return to the OR for new plate placement, of which 2 were infected and 3 had eye symptoms. An external fixator was applied to a local civilian following repeated infections and a nonunion after original ORIF mandible with an avulsive defect from a GSW. The patient was seen in clinic once after the external fixation was placed but no notes for that visit could be found on ALTHA. The postoperative CT scan demonstrated that the pins of the fixator had been incorrectly placed into the maxilla. Discussion This is the first review in the literature to analyze the types of injuries and treatment performed on facial injuries treated at a deployed Role 3 MTF since 2009.15,17–21,24,34 It has the advantage over analyses based on the JTTR alone in that it accurately describes treatment performed on local nationals and provides details on follow-up and surgical complications. It differs from previous publications of those treated between 2004 and 2009 which were almost entirely US and coalition service personnel,15,17–21,24,34 whereas this current population of patients treated was over 70% local nationals. Development of JTS CPGs for facial trauma8 would be useful in guiding management in these complex cases. There was variation in surgical practice during this period, and procedure selection was clearly surgeon dependent. For example, similar segmental dentoalveolar fractures in 6 separate patients were managed differently: one with archbars, one with bridle wires, one with a resin splint, and the remainder with extraction of all of the teeth. Both the archbars and the bridle wires casualties ended up with complications necessitating further teeth extractions. AO principles in such situations recommend that fixation is preferably accomplished with a resin splint attached to at least one neighboring intact tooth on each side of the vertical fracture lines.35 Similar patients with avulsive mandible defects from GSWs were managed with MMF, ORIF with miniplates, and ORIF with a heavy reconstruction plate and an external fixator. This likely reflects both the training of the surgeon treating facial wounds and their maintenance of skills. The complication rates reported in this paper are for local Afghan nationals only and should be interpreted in the context of the mechanism of injury and poor follow-up that occurs in a combat zone. Only 12% of mandible fractures were due to blunt trauma representative of most civilian injuries. Most local nationals were unable to access follow-up after discharge due to security risks, lack of transportation, or because arrangements were made for disposition closer to their family or military unit. Among local nationals, wound infection requiring antibiotics occurred in 16% of all treated fractures with the highest being 43% in mandible fractures not involving the condyles. Direct comparison with other papers on this subject is difficult because of the heterogenous demographics and mechanisms of injury. In the civilian literature, the overall facial fracture infection incidence is approximately 11%,36 and the highest infection incidence is also in the mandible (3–27%).37,38 Previous papers in the military setting from Vietnam and Iraq reported infection rates of 723 and 24%,34 respectively. Of those 16 mandible fractures discharged on oral antibiotics for postoperative infection, 63% subsequently required surgery when they reattended. In particular, all five who developed a long-term nonunion had been discharged on oral antibiotics initially. This would suggest that in this environment, consideration of early repeat surgery is warranted that should infection develop. The second most common complication from facial fractures in this review was limitation in mouth opening (9%). Although this occurs more commonly in high energy wounds, there appeared to be little conformity in the use of MMF. Of the 7 patients with residual limited mouth opening following mandible fracture not involving the condyle, 4 had ORIF and in addition MMF with archbars and tight elastics which was left on at the end of the operation for between 2 and 6 weeks. The use of postoperative MMF with wires or tight elastics in addition to plate fixation in the absence of an additional condyle fracture is not recommended,39 and we would encourage that it be removed at the end of the operation to improve the chances of long-term functional mouth opening. Of the four iliac crest grafts placed, all in local nationals, two failed (50%), both due to infection. All four cases had been managed by internal fixation and had multiple infections prior to the bone graft. It is possible that these cases would have better benefitted from either external fixation to reduce preoperative infection or the use of vascularized grafts such as from the fibula. There is, however, the difficulty in follow-up and access to appropriate nutrition, which may preclude their use in some local nationals. The authors recognize potential limitations to this analysis, in particular its retrospective nature and limited follow-up. In addition, there was a certain degree of subjectivity in attributing complications to procedures. For example, mouth opening was not always measured, even when this was a patient’s primary complaint. It was also not always possible to accurately determine which fracture to attribute complications to such as malocclusion if the fracture was bimaxillary. There is currently a drive in the US Military Health System to develop Combat Casualty Care Knowledge, Skills, and Abilities that would prioritize surgical readiness and ensure that surgeons from all specialities are equipped with the knowledge and skills to deploy. This includes recognizing the differences between treating blunt injury trauma versus high-velocity trauma and how these skills should be maintained once learnt.9 Debate continues whether clinical rotations at a trauma center prior to deployment should be mandated or whether attendance should be required at a predeployment facial trauma course. The UK military have published multidisciplinary guidelines on the management of facial injuries, promoting the initial use of mandibular-maxillary fixation and external fixation of internal fixation for high-velocity or contaminated fractures.40 Currently, no CPG exists for facial trauma, and we would recommend that one be developed. External fixators should be considered in combat mandible fracture injuries where follow-up is possible or temporary stabilization is better suited than immediate internal fixation due to high-energy injury or infected wounds.21,22 Conclusions Although direct comparisons of complication rates from facial fractures treated in the combat setting to that experienced in civilian practice is limited by the nature in which they are reported, this analysis would suggest that complications rates are higher. This likely reflects factors such as energy deposition, infection risk, and time to treatment. Treatment modalities less commonly used in the civilian setting such as external fixators should be considered in particular for complex high-energy or infected mandible fractures where follow-up is possible. Contributor statement J.B.: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; validation; roles/writing—original draft; writing—review and editing. W.G. and J.D.: Methodology; project administration; validation; roles/writing—original draft; writing—review and editing. Ethics statement This study adhered to the Declaration of Helsinki. Informed patient consent was not required due to the nature of the study. This project was approved as a Performance Improvement initiative by the United States Central Command (CENTCOM) Command Surgeon. It was reviewed by the US Army Medical Research and Development Command’s Office of Research Protections, Institutional Review Board Office, and given a Not Research Determination. Level of evidence statement Level 3: retrospective study with up to two negative criteria. ACKNOWLEDGMENTS The authors would like to thank Rebecca Beam, administrator, for accessing archived medical records and Darryl Hoytt, Medweb System Administrator, for accessing archived CT scans. Conflict of interest statement The authors have no declared conflict of interest in the collection and writing up of these results. Permission to publish has been granted by the US Department of Defense and the UK Ministry of Defence. Funding The authors can confirm that no external sources of funding occurred with the production of this manuscript. References 1. Owens BD , Kragh JFJ, Wenke JC, Macaitis J, Wade CE, Holcomb JB: Combat wounds in operation Iraqi freedom and operation enduring freedom . J Trauma 2008 ; 64 ( 2 ): 295 – 9 . doi: 10.1097/TA.0b013e318163b875 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 2. Lew TA , Walker JA, Wenke JC, Blackbourne LH, Hale RG: Characterization of craniomaxillofacial battle injuries sustained by United States service members in the current conflicts of Iraq and Afghanistan . J Oral Maxillofac Surg 2010 ; 68 ( 1 ): 3 – 7 . doi: 10.1016/j.joms.2009.06.006 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 3. Breeze J , Bowley DM, Combes JG, et al. : Facial injury management undertaken at US and UK medical treatment facilities during the Iraq and Afghanistan conflicts: a retrospective cohort study . BMJ Open 2019 ; 9 ( 11 ): e033557. doi: 10.1136/bmjopen-2019-033557 . OpenURL Placeholder Text WorldCat Crossref 4. Lanigan A , Lindsey B, Maturo S, Brennan J, Laury A: The joint facial and invasive neck trauma (J-FAINT) project, Iraq and Afghanistan: 2011-2016 . Otolaryngol Head Neck Surg 2017 ; 157 ( 4 ): 602 – 7 . doi: 10.1177/0194599817725713 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 5. Rustemeyer J , Kranz V, Bremerich A: Injuries in combat from 1982-2005 with particular reference to those to the head and neck: a review . Br J Oral Maxillofac Surg 2007 ; 45 ( 7 ): 556 – 60 . doi: 10.1016/j.bjoms.2007.01.003 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 6. Breeze J , Allanson-Bailey LC, Hepper AE, Lewis EA: Novel method for comparing coverage by future methods of ballistic facial protection . Br J Oral Maxillofac Surg 2015 ; 53 ( 1 ): 3 – 7 . doi: 10.1016/j.bjoms.2014.04.017 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 7. Breeze J , Bowley DM, Combes JG, et al. : Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts; a comparison of treatment at US and UK medical treatment facilities . J Trauma Acute Care Surg 2020 ; 88 ( 5 ): 696 – 703 . doi: 10.1097/ta.0000000000002625 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 8. Farber SJ , Latham KP, Kantar RS, Perkins JN, Rodriguez ED: Reconstructing the face of war . Mil Med 2019 ; 184 ( 7–8 ): E236 – 46 . doi: 10.1093/milmed/usz103 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 9. Breeze J , Combes JG, DuBose J, Powers DB: How are we currently training and maintaining clinical readiness of US and UK military surgeons responsible for managing head, face and neck wounds on deployment? J R Army Med Corps 2018 ; 164 ( 3 ): 183 – 5 . doi: 10.1136/jramc-2018-000971 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 10. Wade AL , Dye JL, Mohrle CR, Galarneau MR: Head, face, and neck injuries during operation Iraqi freedom II: results from the us navy-marine corps combat trauma registry . J Trauma 2007 ; 63 ( 4 ): 836 – 40 . doi: 10.1097/01.ta.0000251453.54663.66 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 11. Breeze J , Gibbons AJ, Shieff C, Banfield G, Bryant DG, Midwinter MJ: Combat-related craniofacial and cervical injuries: a 5-year review from the British military . J Trauma 2011 ; 71 ( 1 ): 108 – 13 . doi: 10.1097/TA.0b013e318203304a . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 12. Breeze J , Gibbons AJ, Opie NJ, Monaghan A: Maxillofacial injuries in military personnel treated at the Royal Centre for defence medicine June 2001 to December 2007 . Br J Oral Maxillofac Surg 2010 ; 48 ( 8 ): 613 – 6 . doi: 10.1016/j.bjoms.2009.10.013 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 13. McVeigh K , Breeze J, Jeynes P, Martin T, Parmar S, Monaghan AM: Clinical strategies in the management of complex maxillofacial injuries sustained by British military personnel . J R Army Med Corps 2013 ; 156 ( 2 ): 110 – 3 . doi: 10.1136/jramc-156-02-11 . Google Scholar Crossref Search ADS WorldCat Crossref 14. Breeze J , McVeigh K, Lee JJ, Monaghan AM, Gibbons AJ: Management of maxillofacial wounds sustained by British service personnel in Afghanistan . Int J Oral Maxillofac Surg 2011 ; 40 ( 5 ): 483 – 6 . doi: 10.1016/j.ijom.2011.01.005 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 15. Salinas NL , Brennan J, Gibbons MD: Massive facial trauma following improvised explosive device blasts in operation Iraqi freedom . Otolaryngol Head Neck Surg 2011 ; 144 ( 5 ): 703 – 7 . doi: 10.1177/0194599811400575 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 16. Brennan J , Lopez M, Gibbons MDD, et al. : Penetrating neck trauma in operation Iraqi freedom . Otolaryngol Head Neck Surg 2011 ; 144 ( 2 ): 180 – 5 . doi: 10.1177/0194599810391628 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 17. Lopez MA , Arnholt JL: Safety of definitive in-theater repair of facial fractures . Arch Facial Plast Surg 2007 ; 9 ( 6 ): 400 – 5 . doi: 10.1001/archfaci.9.6.400 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 18. Brennan J : Experience of first deployed otolaryngology team in operation Iraqi freedom: the changing face of combat injuries . Otolaryngol Head Neck Surg 2006 ; 134 ( 1 ): 100 – 5 . doi: 10.1016/j.otohns.2005.10.008 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 19. Breeze J , Gibbons AJ, Combes JG, Monaghan AM: Oral and maxillofacial surgical contribution to 21 months of operating theatre activity in Kandahar field hospital: 1 February 2007-31 October 2008 . Br J Oral Maxillofac Surg 2011 ; 49 ( 6 ): 464 – 8 . doi: 10.1016/j.bjoms.2010.08.002 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 20. Breeze J , Monaghan A, Williams M, Clark R, Gibbons A: Five months of surgery in the Multinational Field Hospital in Afghanistan with an emphasis on oral and maxillofacial injuries . J R Army Med Corps 2010 ; 156 ( 2 ): 125 – 8 . doi: 10.1136/jramc-156-02-15 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 21. Gibbons AJ , Mackenzie N: Lessons learned in oral and maxillofacial surgery from British military deployments in Afghanistan . J R Army Med Corps 2010 ; 156 ( 2 ): 113 – 6 . doi: 10.1136/jramc-156-02-12 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 22. Gibbons AJ , Mackenzie N, Breederveld RS: Use of a custom designed external fixator system to treat ballistic injuries to the mandible . Int J Oral Maxillofac Surg 2011 ; 40 ( 1 ): 103 – 5 . doi: 10.1016/j.ijom.2010.08.001 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 23. Tinder LE , Osbon DB, Lilly GE, Salem JE, Cutcher JL: Maxillofacial injuries sustained in the Vietnam conflict . Mil Med 1969 ; 134 ( 9 ): 668 – 72 . Google Scholar Crossref Search ADS PubMed WorldCat 24. Brennan J : Head and neck trauma in Iraq and Afghanistan: different war, different surgery, lessons learned . Laryngoscope 2013 ; 123 ( 10 ): 2411 – 7 . doi: 10.1002/lary.24096 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Crossref 25. Brennan J , Gibbons MD, Lopez M, et al. : Traumatic airway management in operation Iraqi freedom . Otolaryngol Head Neck Surg 2011 ; 144 ( 3 ): 376 – 80 . doi: 10.1177/0194599810392666 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 26. Keller MW , Han PP, Galarneau MR, Gaball CW: Characteristics of maxillofacial injuries and safety of in-theater facial fracture repair in severe combat trauma . Mil Med 2015 ; 180 ( 3 ): 315 – 20 . doi: 10.7205/MILMED-D-14-00345 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 27. Petersen K , Colyer MH, Hayes DK, Hale RG, Bell RB: Prevention of infections associated with combat-related eye, maxillofacial, and neck injuries . J Trauma Inj Infect Crit Care 2011 ; 71 ( 2 SUPPL. 2 ): S264 – 9 . doi: 10.1097/TA.0b013e318227ad9a . Google Scholar Crossref Search ADS WorldCat Crossref 28. Holt GR , Jones TK: Chapter 5: Evacuation and roles of care. c1st ed. Borden Institute ; 2015 : 439 – 452 . 29. Holt RG . Chapter 2: History of Deployed Air Force Otolaryngologists in Operation Iraqi Freedom and Operation Enduring Freedom. In: Otolaryngology/Head and Neck Surgery Combat Casualty Care in Operation Iraqi Freedom and Operation Enduring Freedom , Vol. 2015 , Ed Ed. 1, pp 562 – 70 . Borden Institute . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 30. Ministry of Defence : Allied Joint Doctrine for Medical Support . Allied Joint Publication-4.10(B) .Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/457142/20150824-AJP_4_10_med_spt_uk.pdf; published 2015 ; accessed January 10, 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 31. Powers DB : Distribution of civilian and military maxillofacial surgical procedures performed in an air force theatre hospital: implications for training and readiness . J R Army Med Corps 2010 ; 156 ( 2 ): 117 – 21 . doi: 10.1136/jramc-156-02-13 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 32. Kittle CP , Verrett AJ, Wu J, Mellus DE, Hale RG, Chan RK: Characterization of midface fractures incurred in recent wars . J Craniofac Surg 2012 ; 23 ( 6 ): 1587 – 91 . doi: 10.1097/SCS.0b013e318256514a . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 33. VA/DoD Clinical Practice Guidelines . US Army Medical Department. Office of Quality Management . Available at: https://www.qmo.amedd.army.mil/pguide.htm; accessed January 21, 2020 . 34. Salinas NL , Faulkner JA: Facial trauma in operation Iraqi freedom casualties: an outcomes study of patients treated from April 2006 through October 2006 . J Craniofac Surg 2010 ; 21 ( 4 ): 967 – 70 . doi: 10.1097/SCS.0b013e3181e17ab5 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 35. Ellis E , Shimozato K: Dentoalveolar trauma - segmental alveolar fracture - closed treatment . AO Surgery Reference Guide . Available at: https://www2.aofoundation.org/wps/portal/!ut/p/a1/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAwCTYEKIvEocDQnTr8BDuBoQEi_l35Uek5-EtipkY55ScYW6fpRRalpqUWpRXqlRUDhjJKSgmIrVQNVg_Lycr30_Pz0nFS95PxcVQNsWjLyi0v0I1BV6hfkhkZU-aSGAwBJYqzy/dl5/d5/L; published 2019 ; accessed October 23, 2019 . OpenURL Placeholder Text WorldCat 36. Zosa BM , Elliott CW, Kurlander DE, Johnson F, Ho VP, Claridge JA: Facing the facts on prophylactic antibiotics for facial fractures: 1 day or less . J Trauma Acute Care Surg 2018 ; 85 ( 3 ): 444 – 50 . doi: 10.1097/TA.0000000000002009 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 37. Ellis E , Moos KF, El-Attar A: Ten years of mandibular fractures: an analysis of 2,137 cases . Oral Surgery, Oral Med Oral Pathol 1985 ; 59 ( 2 ): 120 – 9 . doi: 10.1016/0030-4220(85)90002-7 . Google Scholar Crossref Search ADS WorldCat Crossref 38. Odom EB , Snyder-Warwick AK: Mandible fracture complications and infection: the influence of demographics and modifiable factors . Plast Reconstr Surg 2016 ; 138 ( 2 ): 282e – 9e . doi: 10.1097/PRS.0000000000002385 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref 39. Schilli W , Stoll P, Bähr W, Prein J: Mandibular fractures. In: AO Manual of Internal Fixation in the Cranio-Facial Skeleton , pp. 57 – 93 . Edited by Prein J. Germany , Springer Berlin Heidelberg , 1998 . doi: 978-3-642-63732-2 . Google Scholar Crossref Search ADS Google Scholar Google Preview WorldCat COPAC Crossref 40. Breeze J , Blanch R, Baden J, et al. : Skill sets required for the management of military head, face and neck trauma: a multidisciplinary consensus statement . J R Army Med Corps 2018 ; 164 ( 2 ): 133 – 8 . doi: 10.1136/jramc-2017-000881 . Google Scholar Crossref Search ADS PubMed WorldCat Crossref © Crown copyright 2020. This article contains public sector information licensed under the Open Government Licence v3.0 (http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/).
TI - Combat Facial Fractures Sustained During Operation Resolute Support and Operation Freedom’s Sentinel in Afghanistan
JF - Military Medicine
DO - 10.1093/milmed/usaa159
DA - 2020-09-18
UR - https://www.deepdyve.com/lp/oxford-university-press/combat-facial-fractures-sustained-during-operation-resolute-support-iurj8cg6rl
SP - 414
EP - 416
VL - 185
IS - 9-10
DP - DeepDyve
ER -