Cases reported "Wounds, Gunshot"

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1/135. Self-inflicted shotgun injuries to the face: a case report.

    Shotgun injuries to the face are difficult to care for due to the often massive tissue and bone destruction and the complications that can accompany these injuries. Psychological responses from the family, significant other, and nursing staff in dealing with disfiguring and sometimes fatal injuries are additional challenges that nurses will face.
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2/135. Neurotologic evaluation of facial nerve paralysis caused by gunshot wounds.

    facial nerve injury is one of the most common neurotologic sequelae of a gunshot wound (GSW) to the head or neck. However, few neurotologic studies have been performed on the nature and time course of such facial nerve impairments. This study was designed to characterize the neurotologic manifestations and time course of facial nerve paralysis caused by GSWs to the head and neck. We conducted a battery of electrodiagnostic tests on 10 patients who had experienced traumatic facial paralysis due to a GSW to the head or neck. The etiologies of facial nerve paralysis--including direct injury, compression, fracture, and concussion of the temporal bone--were demonstrated by audiologic, radiologic, and surgical findings. hearing loss and other cranial nerve injuries were also seen. Six of the 10 patients experienced a complete paralysis of the facial nerve and a poor recovery of its function. We also present a comprehensive case report on 1 patient as a means of discussing the evaluation of facial nerve function during the course of management.
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3/135. Non-free osteoplasty of the mandible in maxillofacial gunshot wounds: mandibular reconstruction by compression-osteodistraction.

    We have treated 33 young men with medium to large (3-8 cm) bony and soft tissue defects of the lower third of the face caused by gunshot wounds. After debridement, collapsing the proximal segments for primary approximation of soft and hard tissues and a closed osteotomy of a small fragment of mandible, we used an original compression-distraction device, designed in 1982 and tested during 1983 (analogous devices were absent at that time) to reposition the mandible and cause callus to form (during distraction) between the fragment and to use the remaining stumps of bone to fill in the defect. The soft tissues were repaired at the same time. Twenty-eight of the patients presented within a few hours of injury, and the remaining five had old injuries. The only complications were in the group with old injuries where four patients developed abscesses that required drainage, but these did not interfere with the process of osteogenesis. All 33 patients had good functional and aesthetic results within 3-4.5 months. The method allows a bloodless minimally traumatic procedure which can be carried out in one stage. The results compare very favourably with the classic methods of the treatment of mandibular gunshot injuries.
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4/135. Nine-year follow-up of successful placement of endosseous implants in a mandibular bone graft.

    Facial trauma injuries secondary to gunshot wounds present a unique challenge. These wounds are avulsive and typically involve the destruction of soft tissue with bone loss. A technique in bone transplantation is that of particulate cancellous bone and marrow. Initial form and stability can be provided by a titanium mesh tray or reconstruction plates while the graft undergoes maturation and consolidation. dental implants can then be placed in this grafted site to provide stabilization for a functional and comfortable prosthesis and for the support of the peri-oral soft tissues.
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5/135. Keyhole defect production in tubular bone.

    Fracture characteristics, reported primarily for the cranium, are valuable indicators of bullet direction. A bullet striking the vault tangentially produces an irregular opening, termed a "keyhole defect." with the circular portion of the defect being the initial point of impact. Identifying this feature in tubular bone (long bone) can also demonstrate bullet direction and the position of the bone at the time of the shooting. This case study involving a tangential shot (i.e., a keyhole fracture) to the humerus demonstrates some of the same fracture mechanics seen in the cranium.
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6/135. Close-range shotgun and rifle injuries to the face.

    The treatment of extensive shotgun and rifle injuries to the face is extremely difficult and demands experience in microsurgery and craniofacial surgery. Early aggressive surgery with immediate bone and soft tissue reconstruction is recommended for the management of extensive facial gunshot wounds. Experience has shown that early three-dimensional bone replacement can be achieved with bone grafts in the midfacial area if the bone grafts are covered with well-vascularized tissues. Large midfacial defects can be reconstructed safely and effectively with free-tissue transfers, including bone. In the acute stage, microvascular muscle flaps are preferred because of their good vascularity and good filling capacity. These flaps are able to cover the anterior cranial fossa. When vascularized bone is needed, the authors' first choice is a latissimus dorsi flap with scapular bone. patients treated with an early and aggressive surgical strategy develop fewer problems in form of infection, contraction, scarring, and require fewer secondary corrections. Successful primary treatment allows the surgeon to use multiple modalities, including tissue expansion, free-tissue transfers, and local flaps in a noninfected environment. The treatment is rewarding, and the results are surprisingly good. It is extremely unusual for patients with self-inflicted gunshot injuries to reattempt suicide.
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7/135. Gunshot wounds to the neck.

    Gunshot wounds to the neck are diagnostically and therapeutically challenging cases. We report such a case with vascular and neurologic injuries and describe the therapeutic options. Initial treatment is aimed at hemodynamic stabilization. Zone II neck injuries are managed selectively, and physical examination alone may dictate emergency surgical exploration. spinal cord injury must be suspected and assessed clinically, as well as by computed tomography and angiography. Deteriorating or stable neurologic status and cord compression by bullet or bone fragments require surgical decompression. Improving neurologic status may be managed conservatively. In gunshot wounds to the neck, treatment should be individualized and multidisciplinary.
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8/135. Primary and secondary microvascular reconstruction of the upper extremity.

    Tissue defects of the upper extremity may result from trauma, tumor resection, infection, and congenital malformation. Restoration of anatomy and functional integrity may require microsurgical free flap transfer for coverage of bones, nerves, blood vessels, or tendons. Microsurgical tissue transfer also may be required prior to secondary reconstruction, such as tendon transfers or nerve or bone grafts. This article addresses indications for upper extremity reconstruction using microsurgical tissue transfer flap selection and strategies including primary and secondary reconstruction.
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9/135. A mouthful of trouble.

    The prehospital providers in this case performed a thorough and detailed assessment. They searched for and found a puncture wound in the posterior buccal region, and learned the patients was also hypoglycemic, with a history of diabetes, and insulin-dependent. It was not clear how the patient arrived at a hypoglycemic state, or if he had suffered a seizure. After the family arrived at the hospital and went to the patient's home, they determined the circumstances that caused this unusual presentation: The patient was the victim of a home-invasion robbery and had been shot in the mouth with a small-caliber weapon. The home invasion had taken place approximately 12 hours prior to the victim being found. The victim had been knocked unconscious by the force of the shot, although the bullet did not break any bones. He had not eaten prior to the shooting. Upon arrival at the ED, a small exit wound was noted behind the patient's left ear--hair and dried blood had obscured it from the prehospital providers. However, the providers did alert the ED physician to the buccal puncture wound, which enabled the physician to consider the possibility that the mouth wound was the result of a gunshot. Gunshot wounds are unpredictable in their damage patterns and effects on their victims. They might lead a patient to become hemodynamically unstable, but that was not the case here. Hemodynamic stability should not preclude the consideration of traumatic insult throughout your assessment. The initial presentation of this patient may have tempted EMS to pursue the suspicions stated by the neighbor at the scene (seizure), but a detailed assessment provided the information necessary to treat the man appropriately.
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10/135. A case of "boomerang" bullet ricochet.

    A .375 Holland & Holland Magnum Winchester Fail Safe bullet was fired against a steel plate. The big-game hunting bullet (17.4 g, approx. 810 m/s) has a solid copper-alloy hollow point design including a lead core limited to the rear portion. The range of firing was 20 m and the angle of impact was 90 degrees. A large fragment (10.9 g) consisting of the main part of the copper portion was deformed in a peculiar manner similar to a tube or ring and wounded the left hand of the person shooting. The unique fragment trajectory strictly against the line of fire and the velocity sufficient to shatter bone after a distance of 20 m can be explained by an extraordinary deformation mechanism. Unlike in tissue, the high resistance of the steel plate caused the lead core in the rear of the bullet to move forward perforating the central copper barrier behind the hollow point cavity. Thus, the peculiar fragment was created. The subsequent backwards acceleration of the ring-like fragment was probably caused by the partly elastic impact of the copper-alloy portion against the hard steel plate. Due to the perpendicular impact resulting in a centric and symmetrical deformation, the fragment moved in a direction exactly backwards along the original line of fire.
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