Cases reported "Wounds, Gunshot"

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1/19. Civilian gunshot wounds to the head with brain stem localization. A case report.

    The authors present a case of a patient wounded to the head and back by civilian firearm projectiles. The case peculiarity is that only one bullet reached the brain stem level causing significant neurological deficits. The final clinical picture is comparable to the "caudal pontine tegmentum syndrome". The authors describe both the bullet path and the intracranial localization taking into account ballistic details. The problems associated with prognosis, diagnosis, and treatment for gunshot wounds are discussed. In addition, the authors explain the main intracranial lesions and their mechanisms, the role of investigation, and the protocol of medical and surgical treatment. Lastly, a systematic approach for treating these types of gunshot wounds is outlined.
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2/19. Options for immediate reconstruction of the traumatized temporomandibular joint.

    The management of condylar fractures is one of the most controversial topics in the repair of the maxillofacial skeleton. An extensive volume of literature exists describing the various indications for a specific treatment of this injury. This article outlines the absolute and relative indications for an open procedure and describes three different modalities for the immediate reconstruction of the temporomandibular joint system. Three different case reports are used to illustrate the respective procedures--replacement of the temporomandibular joint with autologous rib graft, replacement of the temporomandibular joint with an alloplast, and vertical ramus osteotomy for repositioning of the condylar stump. The discussion section reviews the findings and preferences of various treatment modalities described in the literature, along with the advantages and disadvantages.
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3/19. A report on missile injuries in cyprus 1974.

    This paper details the experiences of the Princess Mary's Royal air Force Hospital, Akrotiri (TPMH), during the last 6 months of 1974. TPMH was at that time a small hospital (120 beds) with a clinical staff of 17 situated in the south of cyprus (fig. 1). The series comprises 71 patients injured by bullets, shrapnel, bomb-blasts or mines, drawn from British personnel, united nations Forces and the local Cypriot military and civilian population, resulting from the coup d'etat of 15 July 1974 and the subsequent Turkish invasion and air attacks. The casualties were often severely wounded beyound the capabilities of the local hospitals. They were mostly admitted during a 2-week period, but many required multiple operations extending over the next 3 or 4 months, and altogether 119 operations were carried out on 41 patients at TPMH. The organization of the limited resources of the medical, nursing and supporting staff is outlined. The correct treatment of missile wounds is emphasized. resuscitation, wound excision, splintage and delayed suture or grafting are essential. Minimal morbidity and mortality are gained by a practised approach to the compounded results of violence.
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4/19. Gunshot wounds to the face. Current concepts.

    The primary goal in reconstructing a gunshot wound to the face is identical to that for a major injury of the hand or lower extremity: primary healing of the soft tissue. This prevents the cascade of soft-tissue infection, further delay in healing, bone graft infection, and soft-tissue contracture. Current craniofacial techniques and methods of fixation allow for concomitant bony reconstruction without compromising primary healing of the soft tissues. The result is not only that the soft tissue is healed but also that the original contour, stretch, and pliability are maintained. Once the soft tissue collapses around inadequate bony reconstruction, it is difficult to restore the original situation. Despite the techniques outlined, there is no substitute for sound surgical judgment. Inevitably, cases will arise when the ideal reconstruction cannot be performed because of other injuries, inappropriate initial management at referring institutions, or medical complications. Compromises are then required in the interest of the patient's overall care, with the knowledge that the best chance to restore the anatomy of the hard and soft tissue is in the first few days after the injury.
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5/19. The Mickey Finn defense: involuntary intoxication and insanity.

    The legal context of voluntary and involuntary intoxication is delineated. The author reports a case of involuntary intoxication involving scopolamine toxic psychosis or delirium, in which he testified as a psychiatric expert witness. The specific psychological and physiological symptomatology produced by scopolamine intoxication is outlined. The forensic psychiatrist should be alert to the involuntary intoxication defense in these cases and should familiarize himself with the specific toxicity of scopolamine, in view of the significant increase in the number of incidents in which it is utilized as "knockout" drops in certain jurisdictions.
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6/19. A gun-cleaning "accident".

    A case is presented in which the question of suicide is raised. Several pointers are outlined to help in this differentiation.
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7/19. Venography in penetrating injuries of the extremities.

    Of 30 consecutive cases of penetrating injuries to the extremities studied both by arteriography and venography, five were found to have significant venous injuries. Three of these cases are presented to show the value of venography in detecting inadequate venous collateral circulation, intraluminal thrombus, and venous obstruction. It is suggested that preoperative venography will compliment arteriography, aid in the diagnosis of venous injuries, demonstrate variable venous anatomy, and outline other venous pathology outside of the area of trauma.
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8/19. Management of extremity injuries with external fixator or Ilizarov devices. Cooperative effort between orthopedic and plastic surgeons.

    Major advances in the last decade have improved the treatment and outcome of patients with moderate to severe lower extremity injuries. Better transport and emergency room facilities, which allow more prompt repair of injuries, advances in bone stabilization, and better methods of soft-tissue reconstruction have led to a significant decrease in amputation and infection rates. This article presents the Mangled Extremity Severity Score (MESS) index and Gustilo's classification to evaluate injuries. Orthopedic, plastic, and vascular surgeons collaborate to manage these injuries in five categories: limb viability, timing, debridement, fixation, and secondary reconstruction. Finally, two cases are presented to demonstrate practical application of these steps, and guiding principles are outlined.
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9/19. Intravascular missile embolization in childhood: report of a case, literature review, and recommendations for management.

    A collective review of 20 cases of missile embolization among children (1961 to 1988) is analyzed, one case added, and guidelines for diagnosis and management are outlined. Causative agents were bullets (14 patients), pellets (5), and fragments (2). Their trajectory was arterioarterial (11), venovenous (5), paradoxical (4), and mixed (1). diagnosis was suspected when an exit wound was absent and the foreign body was traced on regional x-ray. Embolization was predominantly to the legs, with a tendency for the left (5 of 8 cases). upper extremity emboli were exclusively to the right. Only one of five cardiac entries required closure to control bleeding compared with four of six aortic. embolectomy was performed in 16 patients. The overall mortality rate was 9.5%. Factors predicting a favorable outcome are early presentation, diagnosis, and intervention; location of cardiovascular entry and embolus site; and presence of soft tissue tamponade at entry wound. Although embolectomy for cerebral, asymptomatic pulmonary arterial, and silent venous emboli is controversial, universal agreement prevails regarding removal of systemic arterial as well as venous emboli that are potentially problematic.
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10/19. Optimum management of hand blast injuries.

    A series of 27 blast and gunshot injuries of the hand is presented. These wounds exhibit a spectrum of complexity and may include extensive soft tissue trauma complicated by burns, foreign bodies, fractures and amputations. A systematic management sequence is outlined to evaluate, treat, reconstruct and rehabilitate these hands, with the primary goal of obtaining early maximal function. Since these injuries vary in nature and complexity, this management sequence is specifically adapted to deal with the individual injury. A "reconstructive ladder" of techniques is utilized, ranging from "simple" (e.g., direct closure, skin grafts, local flaps) to "complex" (free flaps, toe-to-thumb transfer). The individual procedure selected is the most straightforward, consistent with expediency and early return of a functional hand. The return of these hands to function has been facilitated by recent advances in tissue assessment, free tissue transfer, and skilled hand therapy.
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