A Single-Center Review of Facial Fractures as the Result of High-Speed Projectile Injuries

Demographics/mechanisms of injury

The average age of the patients was 29.9 (range, 14-81) years, with a strong male predominance (91.6%). Sixteen (8.4%) of the injuries were self-inflicted. Ninety-seven percent of the weapons used were determined to be low velocity, whereas the remaining 3% were intermediate velocity, and none were high velocity.

Distribution of fractures

Of the 386 fractures recorded in these patients, the most common fractures were of the mandible (23.3%). Fractures of the orbit (20.5%) were the next most common, followed by the zygoma (13.7%) and the nasal bone (12.2%). Distribution of fractures is demonstrated in Figure 2.

Figure 2. Distribution of fractures by anatomical site.

Concomitant injuries

On admission, the average GCS score was 11.9 (range, 3-15). During, or prior to, arrival in the trauma bay, 100 (52.6%) of the patients were intubated and 68 (35.8%) presented with uncontrolled facial hemorrhage. The most common concomitant injury was a skull fracture (31.6%), closely followed by intracranial hemorrhage (29.5%), intrathoracic injury (18.9%), cervical spine fracture (14.2%), pelvic/thoracic fracture (11.6%), long bone fracture (11.1%), intra-abdominal injury (5.3%), and lumbar spine fracture (4.2%). Of the majority of patients (n = 176) admitted to the hospital, 118 were admitted to an intensive care setting. Distribution of concomitant injuries is demonstrated in Figure 3.

Figure 3. Distribution of concomitant injuries.

Services consulted

Fracture cases were managed by plastic surgery, otolaryngology, oral and maxillofacial surgery (OMFS), and ophthalmology. Distribution of services consulted is demonstrated in Figure 4.

Figure 4. Distribution of services consulted.

Fracture management

Surgical management of fractures in the operating room was required in 89 of the 190 patients, the majority of which underwent debridement of devitalized tissue with or without rigid internal fixation. Of the patients treated, 139 (77.7%) were able to be managed conservatively with maxillomandibular fixation whereas 32 (17.9%) required internal fixation and 8 (4.5%) required external fixation (Fig 1c). All other patients underwent some form of bedside irrigation with conservative debridement.

Uncontrolled facial hemorrhage

Of the patients with uncontrolled hemorrhage at presentation, 71% were treated with conservative measures including packing and direct pressure, whereas 22% underwent interventional radiology embolization and 7% required operative vessel ligation.

Soft-tissue management

Only 9 patients required local or regional flaps for soft-tissue coverage. In 1 patient, enucleation and orbitotomy were required to remove the bullet casing and a tarsorrhaphy and a sliding lower lid flap were utilized to close the wound.

Hospital stay/mortality

The mean hospital length of stay was 12.9 (range, 0-228) days. Thirty patients expired. Patients who expired were significantly older than patients who survived, aged 36.4 and 28.3 years, respectively (P < .05). Patients who expired also had a significantly lower GCS score on arrival than patients who survived (5.9 and 13.1, respectively) (P < 0.05).

Demographics/mechanism of injury

There was a heavy male predominance (91.6%), with low-velocity weapons most commonly used. Low-velocity weapons are likely easier to access and to be utilized in a heavily populated urban environment such as Newark, NJ. High-velocity weapons such as rifles can result in a much higher degree of damage, as the fragmented bone from the initial impact can further destroy the adjacent soft tissue.¹² Thus, while low-velocity gunshot fractures are difficult to treat, they are more manageable than intermediate- or high-velocity fractures.

Distribution of fractures

The mandible was the most commonly fractured bone in this study, followed closely by the orbit, zygoma, and nasal bone. Other studies support this finding.^14,15 It is unclear whether this is due to the situations under which these injuries occur or to the location and composition of these specific facial structures.

Concomitant injuries

The most common concomitant injuries were skull fractures, closely followed by intracranial hemorrhage. The lower trunk, including the intra-abdominal region and thoracic and lumbar spine, suffered the least injury. These injuries often take precedence to facial fractures, especially those admitted with a depressed GCS score. Seven of the 17 patients with a GCS score of 3 expired.

In these cases, management of facial fractures is delayed, which can hinder the final aesthetic and functional outcomes by affecting both soft-tissue and bone healing. Infection is also more likely to develop because of these wounds remaining insufficiently debrided secondary to the management of more life-threatening injuries.

Services consulted

Facial fractures from gunshot wounds often present as complex injuries that require interspecialty collaboration. At our institution, these cases are managed by plastic surgery, otolaryngology, OMFS, and ophthalmology. It was surprising how infrequently plastic surgery was consulted, especially in light of the often-associated soft-tissue injuries. This may represent an institutional bias to place more emphasis on the bony injury and is something that we are investigating to attempt to improve the management of these patients at our institution.

Hospital stay/mortality

The mean hospital length of stay was 12.9 days and ranged from 0 to 228 days. Patients with a depressed GCS score were more likely to expire, which is intuitive and is likely a surrogate for the severity of systemic injury sustained.

Soft-tissue management

Only 9 patients of the 190 treated required local or regional flaps for soft-tissue coverage. This can be attributed to the predominance of low-velocity ballistic weapons, as intermediate- and high-velocity weapons often cause more soft-tissue destruction.

Fracture management

The majority of patients were treated conservatively with maxillomandibular fixation, whereas the remaining required internal or external fixation. The fact that the majority of patients required only conservative treatment may be partially explained by the nature of the injury. Most were attributed to low-velocity handgun injuries, which cause considerably less soft-tissue loss and comminution of bone.

In all cases, irrigation and debridement were performed to remove devitalized tissue and foreign bodies from the wound. Maxillomandibular fixation was frequently used because of the presence of concomitant injuries, comminution of bone, and perceived difficulty obtaining a satisfactory result with rigid fixation. In cases where there was a significant loss of bone, external fixation was utilized. Tracheostomy was performed when there was a concern for airway protection or based on discussion with colleagues in trauma surgery.