Fractures chlo. Maxillo facial injury - causes, symptoms, treatment
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Epidemiology
At the age of 3-5 years, the injury of soft tissues prevails, over the age of 5 years - bone injury and combined damage.Classification
Maxillofacial area injuries (chlo) are:- isolated - damage to one organ (teeth dislocation, language injury, fracture lower jaw);
- multiple - variations of the injury of unidirectional action (dislocation of the tooth and the fracture of the alveolar process);
- combined - single-stage injuries of the functional and multidirectional action (fracture of the lower jaw and the cranopy and brain injury).
- closed - without disrupting integrity skin Pokrov (bruises);
- open - with impaired skin cover (abrasions, scratches, wounds).
Depending on the source of injury and the mechanism of damage to the wounds are divided into:
- unimportal:
- ripped and combinations;
- cutting;
- branched;
- chopped;
- Koloty;
- firearms:
- bullet;
- compression;
- electrician;
- burns.
- tangents;
- cross-cutting;
- blind (as foreign bodies may be dislocated teeth).
Etiology and pathogenesis
A variety of external environment factors determine the cause of child injuries. Birth injury- There is a newborn in the pathological generic act, the peculiarities of the obstetric benefit or resuscitation activities. When generic injuries often there are damage to the ENCS and the lower jaw. Household injury - The most common type of child injuries, which is more than 70% of other types of injuries. Household injury prevails in early childhood and preschool age and is associated with falling a child, blows about different items.Hot and poisonous liquids, open flames, electrical appliances, matches and other factors can also cause domestic injuries. Street injury (Transport, non-transport) as a kind of household injury prevails in children in school and older school age. Transport injury He is the hardest; As a rule, it is combined, this species includes braid-maxillofacial damage. Such injuries lead to disability and may cause the child's death.
Sports trauma:
- organized - it happens at school and in the sports section, is associated with the incorrect organization of classes and training;
- unorganized - violation of the rules of sports street games, in particular extreme (roller skates, motorcycles, etc.).
Burning
Among the burnt children are dominated by 1-4 years. At this age, children overturn the vessels with hot water, take an unprotected electric wire in the mouth, play with matches, etc. It is a typical location of burns: head, face, neck and upper limbs. At the age of 10-15, more often in boys, burns face and hands arise when playing with explosives. Fasteners of the face are usually developing with a one-time more or less long-term effects of temperature below 0 C.Clinical signs and symptoms
Anatomy-topographic features of the structure of chlo in children (elastic leather, large fiber volume, well-developed blood supply to the person, not fully mineralized bones, the presence of zones of growth of the front skull bones and the presence of teeth and teeth gains) determine general features manifestation of injuries in children.Injuries of soft fabrics of the person in children are accompanied by:
- extensive and rapidly increasing collateral edema;
- hemorrhages in tissue (by type of infiltrate);
- formation of urban hematoma;
- damage to bones by the type of "green branch".
Ears
In the injuries, there is an increasing traumatic swelling at the place of damage, bruises appears, having a blue color, which then acquires a dark red or yellow-green shade. The appearance of the child with injury often does not correspond to the severity of injury at the expense of an increasing edema and generating hematomas. Ears in the field of chin can lead to damage to the ligabelum of the temporomandibular joints (reflected). Absadins, scratches are primary infected.Signs of abrasion and scratches:
- pain;
- disorder of the integrity of the skin, the mucous membrane of the oral cavity;
- edema;
- hematoma.
Wounds
Depending on the area of \u200b\u200bthe Rounds of Head, Persons and Neck, the clinical picture will be different, but general features For them are pain, bleeding, infection. With the wounds of the near-voltage region, the language, the bottom of the oral cavity, the soft sky often there is a danger of asphyxia of blood clots, necrotic masses. The accompanying changes in general condition are ancient brain injury, bleeding, shock, respiratory impairment (asphyxia development conditions).Face and neck burns
With a small burn, the child actively reacts to pain wech and cry, whereas with extensive burns general state Child heavy, child pale and apatic. Consciousness is fully saved. Cyanosis, small and frequent pulse, cooling limbs and thirst - the symptoms of a heavy burn indicating the presence of a shock. The shock in children is developing with a significantly less lesion area than adults.During the burn disease, 4 phases are distinguished:
- burn shock;
- acute toxmia;
- septicopemia;
- reconvallation.
Frostbite
Frostbite exposed mainly cheeks, nose, ear shells, rear surfaces of your fingertips. The swelling of red or blue-bugs appears. Heat on the affected areas, it is sensible, sometimes a feeling of burning and soreness. In the future, if cooling continues, mass and erosion comes on the skin, which can be secondally infected. Disorders or complete cessation of blood circulation, sensitivity disorders and local changes, expressed depending on the degree of damage and the associated infection. The degree of frostbite is determined only after some time (bubbles may appear on the 2nd-5th day).4 degrees of local frostbite:
- I degree is characterized by a blood circulation disorder without irreversible damage, i.e. without necrosis;
- II degree is accompanied by necrosis of surface layers of the skin to a spike layer;
- III degree - total skin necrosis, including a sprout layer, and subject to layers;
- with IV degree, donate all the fabrics, including bone.
By origin, injury is divided into:
1) Production:
a) industrial;
b) agricultural.
2) non-manufacturing: household (transport, street, sports, etc.).
1. Mechanical damage top, middle, lower and side zone
Localization:
A. Injuries of soft tissues with damage:
c) large vessels
d) large nerves
B. Bone trauma:
a) lower jaw
b) upper jaw
at) zhilogo bones
d) nose bones
e) two bones and more
2. By character injury: through, blind, tangent, penetrating the oral cavity, do not penetrate the oral cavity penetrating into topper dasukha And the cavity of the nose
3.Abe the mechanism of damage
a) bullet;
b) convolver;
c) balls;
d) sweat elements.
A. Firearms: bullet, fragmentation, ball, sweat elements.
4. Combined lesions
1) radial;
2) poisoning chemicals.
6. Highness
Damage divide on: 1) Isolated, 2) single, 3) Isolated multiple, 4) Combined isolated, 5) Combined multiple.
Injury- These are damage to the tissues, organs, vessels, bone destinations, as a result of the actors of the external environment.
Disturbance of skin care, soft tissues. These are all wounds. Depending on the mechanism of injury, the wounds are distinguished: cutting, crushing, chopped, torn, bruised, firearms.
The task of the average health worker to determine: view of the wound. Chicken wounds Apply with a stitching gun. Such wounds are very cunning, since in the first hours they do not give expressed symptoms. When applied to the stomach, it is possible to injure the stomach, the liver, the legs of the selection or the bile, no gastric juice due to the narrowness and depth of the wound channel. The clinical picture occurs through a large period of time when symptoms of peritonitis appear.
Combined injury - Damage of 2 or more anatomical areas with one or more affixing agent.
Combined injury - Damage resulting from the impact of various traumatic factors.
Fracture - partial or complete violation of bone continuity.
Traumatic damage to teeth
Severe acute and chronic tooth injury.
Acute tooth injury - It occurs with the simultaneous effect on the tooth of great strength, as a result of which injury, dislocation, the fracture of the tooth, is more common in children, the front teeth of the upper jaw are mostly traumatized.
Chronic teeth injury - It occurs under the action of a weak amount of force for a long time.
Rezany woundsapplied to the sharp object, more often with a knife. These wounds are more favorable in terms of healing, as the edges are smooth and wound gapies.
Chopped wounds They are applied with severe acute subject, usually ax. Such wounds are heavier, as the wound gaps wide and the bruise and concussion occurs, which reduces their resistance.
Harried wounds - This is when the blow is applied to a wide item at high speed. Such wounds are large with irregular shape with ribbon edges.
The presence in the wound large number of bruised and dead tissues makes these wounds very dangerous in relation to infection.
Penetrating wounds Very dangerous due to the possibility of damage to the shell of cavities and internal organs.
Approved by the solution of the problematic commission "on issues surgical dentistry and anesthesia "with the scientific council on the dentistry of AMN USSR on March 16, 1984, the classification includes the following sections.
I. Mechanical damage to the upper, middle, lower and lateral zones of the face. 1. Localization. A. Injuries of soft tissues with damage:
b) salivary glands;
c) major nerves;
d) large vessels. B. Bone trauma:
a) lower jaw;
b) the upper jaw;
c) zick bones;
d) nasal bones;
e) two bones and more.
2. By character injury:
a) cross-cutting;
b) blind;
c) tangents;
d) penetrating: in the oral cavity, nose, maxillary sinus;
e) not penetrating: in the oral cavity, nose, topless
e) with a defect of tissues - without a tissue defect;
g) leading - associated;
h) single - multiple;
and) isolated - combined.
3. on clinical flow wound process:
a) complicated;
b) uncomplicated.
4. By the damage mechanism. A. Firearms:
a) bullet;
b) fragmentary;
c) balls;
d) sweat elements. B. Unimportal.
II. Combined lesions.
III. Burns (including electrician).
IV. Frostbite.
Damage can be isolated and combined, single and multiple, leading and related, as well as combined.
Isolated called wounds of one anatomical area.
Combined call damage to two anatomical regions and more.
Single isolated wound occurs with the defeat of one anatomical region with one wound agent.
A single combined wound occurs with the defeat of several anatomical areas with one wounding agent (for example, the wound of the head and hand of one bullet).
Multiple isolated damage occurs when a single anatomical region is injured by several wounded agents (for example, several bullets or fragments).
Multiple combined wound occurs during the damage to several anatomical areas as a result of the action of many wounding agents (for example, the injury, chest, etc., several bullets or fragments).
Leading damage determine the severity of injury in the presence of several injuries.
Related damage occurs simultaneously with the leading, but do not determine the severity of injuries compared to leading.
Leading and related injuries can change roles depending on the timing and effectiveness of treatment.
Combined are injured by one or more anatomical areas resulting from the impact of different affecting factors (for example, mechanical injury and radiation damage or thermal effect, or exposure to high frequency currents).
The clinical course of injury and its outcome is determined by the volume of affected tissues and the damage mechanism (view of the wounding projectile). Firearms are often accompanied by damage to large nerves and vessels, shaking or brain injury, damage eye apples, trachea, larynx, hearing organs, i.e. Quite often relate to combined wounds.
During the Great Patriotic War, 97.1% of all injuries accounted for firearms. In local wars, firearms of the face amounted to 85.5%.
According to international ClassificationThe whole body of a person is conditionally divided into 7 anatomical areas: head, neck, chest, belly, pelvis, spine, limbs. In turn, additionally allocate the following areas of the head: skull and brain, chlo, ENT organs and organs of vision. Given the proximity of their location, injured face is most commonly combined. These include such damage under which at least one of the regions: skull, brain, body of vision, LOR-organs - and in the treatment of which is needed by the participation of neurosurgeon, oculist or otorinolaryngologist.
Small weapons are conventionally divided into 2 groups:
Rifle weapons of various caliber, affecting the element of which are bullets;
Explosive ammunition affecting elements of which are fragments and explosive wave.
The slaughterings are considered to be shells weighing 4-5 g at a flight speed of 200 m / s or more, i.e. The impact force is 15 kg / m. Currently, the caliber rifles 5.56 and 7.62 are dominant with bullets weighing 3-4 and
Depending on the flight speed, shells distinguish:
Low-speed (up to 700 m / s);
High-speed (700-990 m / s);
Ultra-speed (more than 1000 m / s).
To damage the tissues, there is enough energy 70-80 J. At the same time, for example, a TT caliber 7.6 pistol with an initial rate of a bullet 300 m / s (low-speed, mass 8 g) has an energy of 400 J, which is more than 8 times greater than 8 times The energy required for fabric damage.
To form a wound, the kinetic energy of a wounding agent, which is calculated by the formula:
E \u003d (M x V 2): 2,
where m is the bullet mass, V is its initial speed.
Thus, the initial rate of the traumatic agent (bullets, fragments) mainly determines its kinetic energy and, consequently, its shock force and the volume of tissue destruction.
A wounded agent (bullet, fragment) when hitting the body causes the defeat of the tissues of the following species.
1. Direct exposure to fabric (direct destruction), which is customary to be called "direct blow." It is manifested by the formation of a wound channel with a breaking of its walls, their mischief and death, as well as infection.
2. Indirect effect on fabric, called "side, or hydrodynamic blow", as well as a "molecular concussion of tissues". The side blow arises due to the formation of a temporary pulsating cavity (runway), which causes a disruption of microcirculation in the tissues surrounding the wound channel, and pronounced pathological changes in the wall of the wound channel (thrombosis of small vessels, hemorrhage, cell lysis, necrosis, etc.). The volume of the zone of the side impact damage depends mainly on the kinetic energy of the traumatic agent and to a lesser extent - from the structure of the struck tissues.
Thus, the formation of the wound occurs in 2 stages. At the first stage, the straight blow is primary due to the head shock wave. It is a compressed
before the flying traumatic agent, the aircraft, which, in contact with the skin, causes her gap, after which the bullet or fragment rushes over the aircraft in the resulting skin wound, expands it, moves forward, into soft tissues, destroys them and strates, creating the wound channel. Following the destruction of soft tissues (skin, fiber, fascia, muscles, tendons), bones and organs may occur.
In the course of the walls of the wound channel, the zone of primary necrosis fabrics is formed due to the immediate effect on their traumatic agent.
It should be noted that during the movement of the bullet (fragment) before it accumulates tissue content consisting of destroyed cells. In this area formed high blood pressureAs a result of which liquid tissue content penetrates between the walls of the wound channel and the traumatic agent, after which it turns out through the inlet. Behind the tissue of the tissue by the traumatic agent through the outlet also destroy the ruined fabrics. As a result, during damage to the bone, the outlet will be significantly larger than the input.
The impact of direct impact is very short and is only 0.0001 to 0.001 s.
At the second stage of damage formation, when the projectile leaves the wound channel through the outlet or remains at the end of the wound, along the wound channel, another force in the form of a side (hydrodynamic) strike at the expense of the WFP education is affected.
The resulting WFP leads to very frequent strong contacts (shocks) of the walls of the wound channel (according to the type of cotton in your hands), causing the death of the adjacent tissues due to damage to cells, capillaries and small vessels. This phenomenon is also called a "molecular concussion", which leads to a pronounced morphological (mainly hemorrhage, climber thrombosis and tissue thrombosis) and functional disorders in tissues at a considerable distance from the wound channel.
So the zone of secondary, or consistent, tissue necrosis is formed. It is located in the duck from the wound channel tissues, which were directly acting a bullet (fragment). Its width is directly proportional to the kinetic energy of the traumatic agent and can reach several centimeters.
The death of fabrics in this zone occurs gradually due to cavitation damage to subcellular structures (molecular concussion), the subsequent impaired microcirculation (thrombosis and hemorrhage of capillaries) and tissue proteolysis due to the release of enzymes in the primary necrosis area.
In the zone of secondary necrosis there is a pronounced braking exchange processes, violation of metabolism of nerve endings and the formation of a large number of non-visual fabrics.
The operation of the runway lasts 0.04-0.19 s (i.e., 300-500 times longer than the effect of direct strike), therefore, after the wounded projectile leaves the tissue.
The area of \u200b\u200bsecondary necrosis follows the parabiosis zone. Here the fabrics retain their livelihood, although some time and are in parabiotic state due to gunshot wound. This state is reversible, since the thrombosis and hemorrhage of capillaries or the severity of these changes is rather minor. When conducting primary surgical processing (PHO) Fireplaces of fabrics must be excised to this zone to prevent the development of inflammatory complications.
Behind the parabiasis zone is unaffected fabric (Fig. 1-1).
The wound channel may not have a direct direction, but also a winding direction due to the possible deviation of the bullet while driving as a result of its contact with bone tissue. This phenomenon is called "primary deviation". In addition, the winding direction can occur due to varying degrees of muscle contraction, ligaments and fascia after passing through the traumatic agent. In this case, we are talking about "secondary deviation" of the wound channel.
Fig. 1-1. Wound Canal Zones(Scheme): 1 - Primary necrosis area (post-traumatic); 2 - the zone of secondary necrosis (molecular concussion); 3 - parabiosis zone; 4 - unaffected fabric
Thus, for a gunshot wound, the presence of the following 4 zones is characteristic (see Fig. 1-1) and the following features:
Damage to the skin;
Possible presence in the wound of foreign bodies;
Primary and secondary wound channel deviation;
Microbial fabric contamination.
Summarizing the foregoing, you can note the following.
The degree of volume of the destruction of tissues and organs depends on the kinetic energy of a wounding agent. What it is more, the more significant tissue destruction.
New types of rifle weapons have a significantly greater initial flight rate of the traumatic agent than old, and therefore have greater kinetic energy. The bullet quickly gives this energy to damaged tissues and organs, causing significant destruction in them.
WFP causes the so-called intractaneous explosion, which determines the degree of tissue damage along the wound channel, destroys the tissue for a fraction of a second and continues to operate after a wounded headile leaves the tissue through the outlet. Therefore, firearms of the person are accompanied by the formation of significant defects of soft tissues and bones, the formation of a large number of non-visual fabrics. These wounds lead to severe functional disorders and urgently appearance of the victim. Often there are such early complicationsAs asphyxia, shock, bleeding, etc., which in the future lead to the disability of a patient or a fatal outcome.
The degree of destruction of tissues depends on both the power of the traumatic agent and the morphological structure of damaged tissues (their elasticity, strength). At the same time, due to the high strength and fibrous structure, the fascia may be preserved, and the muscular tissue is subjected to complete destruction. At the same time, the bone and teeth, having a large resistance to the pool, absorb a significant amount of kinetic energy of a wounding projectile and destroyed with an explosive effect. Their fragments can turn into "secondary wounding shells", which, purchasing kinetic energy, will continue to destroy the surrounding tissues in the future.
Blood filling such large vessels as internal carotid artery and jugular veincan get energy under the law of hydrodynamics and put a straight blow to the head fabric
brain. This is capable of concussion and other damage, as well as determine the tears of the neck and head vessels.
The nerves have high elasticity and resistance to the rupture, but in them, by virtue of direct or lateral blows, there may be impaired conductivity, which leads to terrains or paralymps of the muscles.
Firearms can be through, blind and tangent.
Through firearms occur, as a rule, when passing a bullet only through soft tissues and have two holes: input and output. In case of damage to the bone tissue, the through wound occurs in the event that the injured agent has significant kinetic energy capable of not only to destroy the bone, but also leave the body.
Through injuries are 36.5-47.4%. The size of the inlet is usually significantly less than the output, especially when damaged bone tissue. This is due to the fact that the traumatic agent introduced into the tissue gives them part of their kinetic energy. Bone tissue, having received a certain stock of energy and becoming a secondary wounding projectile, delivers additional anatomical destruction. Destroyed soft and bone tissue move along with a bullet on its trajectory, increasing in the amount, and the output creates additional tissue destruction.
Cell-through wounds are 8 times more often applied by bullets than fragments. With through wounds, especially with the damage to bone tissue, the greatest mortality and the lowest number of issued with complete recovery was observed.
Especially large destruction of persons are marked with fragmentation wounds.
Blind wounds occur in the case of low kinetic energy of a traumatic agent or a rapid return of energy when it passes in tissues. The blind injection is characterized by the presence of the inlet and the wound channel, which blindly ends in the tissues. There is no output hole. During the examination of the blind damage, a traumatic agent is always detected in the wound.
Blind wounds on average are found at 33.1-46.2% of cases. Most often, they relate to the lungs and in some cases do not require radical surgical treatment. However, if a fragment or bullet is near a brain, large vessels, larynx,
the tracheas and nervous trunks, there are a danger of damage or the subsequent development of a serious inflammatory process, which is observed in 40% of cases. That is why it is necessary to determine the location of the fragments, and the blind injuries are considered potentially difficult.
Blind wounds are more often fragmentation (89.5%), less often - bullet (10.2%). In local wars, the bullets are marked in 43.5% of victims, fragments - 56.5%.
Multiple blind, fine wounds cause persistent disfigure of the face and belong to heavily. In 9.3% of cases of multiple blind injuries, the foreign bodies were in the region of the vascular beam, which was a potentially practical prognostic sign.
Anamnesis, study of the recorded documentation, palpation of tissues in the field of squeezing, finger surveys, sounding, fistulography and vulnerography is used to diagnose blind injuries.
It is necessary to remember the possibility of deviation of the wound channel, which is accompanied by its shortening or lengthening, as well as fragmentation, which significantly complicates the search for a fragment during PHO.
Blind of languages \u200b\u200bare 3.2% of all blind injuries.
If the foreign body does not provoke the inflammatory process, it may not be subjectively determined by the wound. When the lateralization of the foreign body in the deep departments of the language, as well as in the regional and capped spaces, there is a real danger of the development of phlegm of these areas, and therefore the removal of the foreign body is necessary and implemented according to urgent testimony.
Indications to remove bullets or fragments:
1) Localization of a fragment near a large vessel;
2) Localization of a fragment near the esophagus, pharynx, larynx, if it makes it difficult, swallowing, breathing;
3) the presence of an acute inflammatory focus due to a foreign body.
Tangential injury of the face occurs with the surface passage of the traumatic agent in relation to the tissues. As such, the inlet and outlet are not determined, and there is an extensive wound surface. Wounding shells dissect soft fabrics of the face throughout the wound. In its edges, it is possible to determine small gaps that form the diplocked outlines,
scramble and bruises. Sometimes the tangent wound reminds a chopped wound. Like all wounds, it can be contaminated by parties of an explosive.
Tangenties are found in 14.4-19.5% of cases, they are usually referred to by the number of lungs. However, a small part (5%) of tangent wounds may be accompanied by the formation of tissue defects; They are related to the category of hard, especially in the case of a shot of a nose or chin. Complications arise in 30.2% of victims with these wounds.
Wounds penetrating the oral cavity, the nose, the maxillary sinus, are found in 48.6% of cases, they are always infected, their current is always heavy. It should be noted that 55.1% of victims are returned to the system, while ironsistent - 80.5%. Penetrating injuries were given by 3.5-4.5 times more complications compared to imperminating.
Wounds with a defect of soft tissues during the Great Patriotic War made up 30.9%, with a defect of bones - 13.9%.
The multi-sized bone fractures after the firearms of the face were most often (87.8% of cases), linear less often (12.2%). It should be noted that firearms of the face with damage to the jaws refer to the category of relatively treble.
Insulated firearms of CLO are 40.2% of the total number of injuries, combined injuries of the face - 42.8%.
When using nuclear weapons, the number of victims with burns and radiation damage is increasing, as well as with uniform wounds due to the effects of the shock wave and secondary wounding shells, i.e. There is an increase in the number of combined injuries.
The greatest number of complications were given through wounds (70%), smaller blind (43.5%) and the smallest - tangent (30.2%) relative to each group separately.
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test questions
1. List the features of traumatic damage to the maxillofacial area.
2. What is meant by the concept of "inconsistencies external view And the severity of damage "? What is the practical significance of this concept?
3. What is life important organs and functions are broken upon traumatic damage to the maxillofacial area?
4. The presence of what anatomical formations is fundamentally distinguished by the maxillofacial region from other areas of the human body?
5. What feature is the vessels of the maxillofacial region, in contrast to the vessels of other areas of the body?
6. What features of soft tissues of the maxillofacial region are promoted by increased regeneration?
7. What positive and what negative sides Are the presence of teeth?
8. Is it possible to use the wounded ordinary gas mask, and if it is impossible, then why and what is used?
Chapter 3.
General characteristic of traumatic Damage to soft tissues Maxillofacial region
Damage to soft tissues can be open and closed.
Damage is considered open damage, accompanied by a violation of the integrity of the coating tissues to which the skin and the mucous membrane belong. These damage are referred to as a wound. The wound has three main features - pain, bleeding and the gaping (the discrepancy of the edges). Closed injury is characterized by two signs - pain and bleeding. In this case, there is no gaping of the edges of the wound of the skin or mucous membrane. The closed injury of soft tissues is manifested by the bruises, which are a consequence of a non-stroke to face a stupid subject with damage to the subcutaneous fiber, mimic muscles Without breaking them and vessels located in the damage zone. Two bleeding options are possible:
- with the formation of the cavity - when blood is fused into the interstitial space, in this case hematoma is formed;
- icing blood with blood fabrics, that is, impregnate them without the formation of cavities.
Depending on the localization of hematoma, there may be superficial and deep. Surface hematomas are located in the subcutaneous tissue, and deep - thicker or under the muscles (for example, under chewing, temporal), in deep spaces (for example, a wonderland-jewish, in a metallic fossa, in the field of a dog jam), under the periosteum.
Surface hematoma and icing blood tissue is manifested by a change in skin color. The skin over the hematoma first has a crimson-blue or blue color ("bruise"). Such a color is due to the decay of red blood cells with the formation of hemosidirin and hemotoididine. Over time, the color changes to green (after 4-5 days), and then yellow (after 5-6 days), finally hematoma is absorbed after 14-16 days.
The hematoma, located in the wonderland-jewish, tidy or advocacy spaces, can cause difficult opening of the mouth. The hematoma, formed in the wonderland-maxidial, octopic, sub-language areas and the area of \u200b\u200bthe root of the tongue, can lead to difficulty swallowing. All of the above hematomas relate to deep, which is why their diagnosis, that is, the definition of the presence of the hematoma in these spaces is difficult.
The presence of hematoma in the field of a dog pammka, due to the compression of the lower ninegal nerve, can cause a disruption of innervation sensitivity to this nerve (skin of the under-judicial region and the wing of the nose, the incisors of the upper jaw), which should be considered when differential diagnosis Hematomas with a fracture of the upper jaw along the lower ordrawal edge.
The hematomas in the field of mental hole may also be accompanied by loss of sensitivity in the chin and the lower lip of the corresponding side, which should be taken into account with the differential diagnosis between the soft tissue injury and the lower jaw fracture in the art.
Deeply located hematomas can manifest themselves on the skin after 3-4 days. Hematoma is always accompanied by post-traumatic edema. He is especially manifested in injury in the field of the eyelids. At the same time, it should be remembered that in case of damage to the under-judicial region, there is often swelling of the age not only due to the hematoma, but also due to the compression of lymphatic vessels, which provide lymphotok, which in turn leads to lymphostase and century. As a result of the hematoma, there may have three development options: resorption, encapsulation and suppuration. In the second and third cases it is necessary to drain the hematoma in stationary conditions followed by anti-inflammatory treatment.
TO closed injury An abrasion of the skin can be attributed when only skin epidermis is damaged, and surface damage to the oral mucosa.
3.1. Clinical characteristics of uniform damage to the maxillofacial region
Characteristics of non-inflatable wounds:
- the wound canal, as a rule, is even, the defect of the tissues is absent, with the exception of ripped, bruised and busted wounds;
- the zone of primary necrosis depends on the type of weapons;
- the secondary necrosis zone is associated with the development of inflammatory processes, the presence of a defect of soft tissues, accompanying damage to the bones of the facial skeleton, circulatory impairment and innervation;
- The severity of damage is due to the inclusion of weapons with soft tissues, the type of weapon, the strength and speed of impact, the structure of the tissues.
Rezany wounds It can be applied to a dangerous razor, a safe razor blade, glass fragments, knife and other cutting items.
The nature of the wound in this case is significantly different from the nature of the firearm wound. Input and outlet openings, as a rule, one value, the wound channel is smooth, along the wound channel of the tissue is rarely necrotized. The edges of the wound are well brought together and compared. The edges of damaged blood vessels and nerves are smooth, which greatly facilitates the possibility of their detection, followed by dressing or imposing seams. Penetrating injuries in the apparent cavities of the nose and the oral cavity should be attributed to the end-cutting. By severity, through injuries of soft fabrics of the face are lighter than the blind. However, in case of damage to the muscles involved in the movement of the lower jaw, large vessels (facial and paternal arteries), soft nose, large salivary glands (varnish, lifting, sub-surge) clinical current injuries should be assessed as moderate severity.
Chicken woundsafter applying injury to acute, thin weapons (style, needle, bayonet, awl) or other any weapon having a long thin body. The peculiarity of the wounds is that with small visible damages, the depth may be significant. The wound canal may affect not only the muscles, but also deeply located vessels, nerves, salivary glands, maxillofacial space and cavity. That is why careful revision of the wound and the survey of the patient is necessary. Cheerful wounds are often accompanied by the development of deeply located purulent processes (phlegmon, abscesses), which contributes to the infection of the wound, the absence of a wound separated due to the low magnitude of the inlet, the presence of intrabate hematoma, which is formed in the depth and is a good nutrient medium for the development of purulent processes.
Chopped wounds.The character of the chopped wound depends on the acute weapon, its weight and the forces with which injury is inflicted. Chopped wounds are a consequence of a heavy sharp object (for example, an ax). They are characterized by a wide wound gaping, injury and concussion, may be accompanied by damage to the bones of the facial skeleton with the formation of fragments.
Bruised I. ripped wounds - The result of the impact of a blunt subject. They are characterized by the presence of bombarded tissues. The edges of such wounds are uneven. There is a defect of the tissues, as well as damage to the bones of the facial skeleton. Blood vessels are often thrombwing, which in turn leads to a violation of the blood supply to the affected area and to necrosis. Perhaps the occurrence of hematoma. The flow of such wounds as a result of infection and violation of blood supply is accompanied by the development of the inflammatory process. In this case, the wound heals the secondary tension, the scars are formed, which leads to the defense of the face. The bruised wound can be patchwork.
Branched woundsthere are damage to the soft tissues of human or animals with teeth. Characteristic features branched wounds are damage in the form of two arcs; In the center - there is no longer-resistant film, apokraam - rounded (funk-shaped) from the fangs. The branched wounds are characterized by torn edges, often accompanied by fabric defects, especially the protruding parts of the face - the nose, lips, the ears, as well as the language, and the high degree of infection. Complicated wounds are heated by secondary tension with the formation of deforming scars. With soft tissue defects, it is necessary to conduct plastic Operations. Through the bite can be transmitted pathogens of syphilis, tuberculosis, HIV infection, etc.
In the bite of animals (dog, cat, fox, etc.) may occur with rabies or sap (horse). Therefore, it is necessary to find out which animal caused a bite (homemade, unprecessful or wild). In all cases, in which it is impossible to find out the condition of the animal, immunization against rabies is needed, which is carried out by a surgeon-traumatologist who has special training for the provision of anti-gravity to the population. Immunization is carried out in polyclinic or inpatient conditions in accordance with the instruction on the use of anti-grades.
Uniform wounds can be combined with the presence of a foreign body in the wound. It can be glass, brick, soil, pieces of wood, i.e. those materials that were at the place of damage to damage. In the dental practice of the foreign body there may be an injection needle, bors, teeth, sealing material. The localization of them is possible in soft tissues, maxillary sine, the mandibular channel. Endodontic tools should also be attributed to the foreign body - Dril-Bor, to-file, n-file, channel filler, pulpxtractor, sphered, etc.
3.2. Clinical characteristics of firearms of the maxillofacial region
In the firearm formation mechanism, the basic value belongs to four factors:
- Impact of the shock wave;
- Impact of a wounding projectile;
- the effect of lateral impact energy, in the process of which the temporarily pulsating cavity is formed;
- Impact of the vortex trace.
In case of unityless injury and damage, only one of four factors is important - the impact of a wounding projectile. Firearms, in contrast to uniform, are characterized by the destruction of tissues not only in the zone of the wound channel (primary necrosis), but also beyond the formation of new foci of necrosis within a few days after injury (secondary necrosis). Three damage zones can be distinguished:
- zone of the wound canal;
- the zone of contusion or the zone of primary necrosis, i.e., the zone of the one-time necrotization of soft tissues due to direct impact;
- Common zone (Lat. commotio.- concussion) or a molecular concussion zone associated with the action of kinetic energy strength, which occurs when using high-speed small arms. As a result, a pulsating cavity is formed high pressure, Tens of times superior to the diameter of the wound channel and 1000-2000 times longer than the passage time of the wounding projectile. This explains the emergence of sections of secondary necrosis, which is focal in nature.
The clinical picture of the damage to the soft tissues of the Chelyusnolistse region largely depends on the type and shape of the wound object. Firearms, unlike unnoticed, are more severe, often accompanied by damage to the bones of the facial skeleton, defects of soft tissues, violation of vital functions (breathing, chewing, etc.).
According to the data obtained in a comparative analysis of firearms of the maxillofacial region during the GOI and modern LDV, the frequency of them, depending on the nature of the damage, is distributed as follows:
- end-to-end - 14.6% (WFAS) and 36.5% (LDK);
- blind - 79.6% (GOB) and 46.2% (LDK);
- tangents - 5.7% (GOB) and 14.4% (LDK);
The increase in cross-cutting firearms in the LVC compared with the period of the Second World War can be explained by increasing the specific weight of the use of high-speed firearms.
Three heavy gunshot wounds are through. They are characterized by the presence of the inlet, the wound channel and the outlet. If the inlet may be small, then the outlet exceeds the input to several orders. This is explained by the fact that when introducing a bullet with a displaced center of gravity in the body, it passing through the fabrics, turns over and goes into the transverse position. The presence of a pulsating cavity and the development of kinetic energy leads to extensive destruction in the course of the wound channel. A large amount of necrotic tissue, the edges of blood vessels and nerves are smakeed.
Blind wounds are characterized by the inlet, wound channel and a foreign body.
Foreign bodies are classified according to the following features:
1. In relation to the RG-rays:
- X-ray-contrast;
- non-X-ray-contrast.
2. On localization of finding:
- in subcutaneous tissue, in muscles;
- with damage to the bones;
- in the applied cavities of the nose;
- in the deep spaces of the maxillofacial region (walled-shaped, octopic, bottom of the oral cavity);
- in the thickness of the language;
3. By the form of a wounding projectile:
- the Shard;
- Teeth that are outside the wells (secondly wounding shells);
- Others.
Causes requiring compulsory destruction of foreign bodies:
- the foreign body is in the plane of the fracture;
- the foreign body is near the vessels, which can lead to the development of layers of the vessel and the emergence of secondary early, and sometimes late bleeding;
- the presence of constant pain;
- limitation of the movement of the lower jaw;
- disruption of breathing;
- long inflammation;
- Finding a foreign body in the applied cavities of the nose.
Terms and location of the foreign body depends on the situation in which the wound was obtained. In the course of hostilities, the operation to remove the foreign body is due to the military and medical situation and evacuation conditions.
V. I. Voyachek (1946) allocates four combinations of the ratio of local and general reactions for the presence of a foreign body, on which it depends on its removal:
1) Easy access to the foreign body in the absence of unpleasant consequences associated with it (extraction in favorable conditions);
2) Easy access, but there is a pronounced local or general reaction (extracted with the first to be the opportunity);
3) difficult access, but there is no reaction to the foreign body (extracting only with particularly reasons);
4) difficult access, but in the presence of unpleasant sensations or threatening symptoms (extracted in compliance with the necessary precautions).
In connection with the above indications for the removal of foreign bodies can be divided into Conditional, absolute and relative.
If the founding of the foreign body is safe, does not cause functional disorders and can be easily removed, then such indications are related to conditionaland the removal of the foreign body can be carried out at any time and at any stage of medical evacuation depending on the medical and military situation.
If the removal of the foreign body does not represent complexity, and the presence of it is dangerous for life, then the testimony for its removal absolute. In this case, the operation is carried out in the next time.
If the removal of the foreign body is technically difficult and can lead to large complications than the presence of a foreign body, the removal is performed when providing qualified or specialized assistance and then indications for the removal of a foreign body can be considered relative.
In peacetime, the wounded is delivered to the hospital, where he should be provided with specialized assistance in order to remove the foreign bodies. In the preoperative period, an x-ray examination is necessary. With a standard examination, two x-ray pictures are made in two projections - direct and lateral, in order to determine the localization of the body in space with respect to anatomical benchmarks. Other methods of x-ray examination are possible: orthopantomogram, cT scan and etc.
During the primary surgical treatment, the revision of the wound canal and regions adjacent to it are required. The visual detection of the foreign body is especially important if the presence of non-X-ray-contrast materials is suspected. In the maxillofacial area, additional cuts are impossible in order to search for a foreign body. In addition to the visual examination of the wound channel in the primary surgical processing, an endoscopic examination can be used (A. S. Samoilov [and others], 2006). In case of doubt about the presence of a foreign body, the imposition of a deaf seam during primary surgical processing is not recommended. Deaf seams can be imposed in 5-7 days, making sure the absence of the inflammatory process. During the entire observation time in order to reduce the gaping of the edges of the wound, it is possible to use the bands of the leukoplower, the imposition of plaminar or rare seams (see Fig. 24, 25). In fig. 4, 5, 6, 7, 8 are examples of various types and location of foreign bodies.
The severity of damage to the soft fabrics of the face depends on the localization of the wound, the volume of tissues in the area of \u200b\u200bdamage, and the type of wounding projectile. However, for any injury, the course of the wound process, which is conditionally divided into four periods. (Conditionally, because the transition from one period to another is not sharp, but gradually. For one period, the development of the other begins.)
First periodit is limited to 48 hours and is characterized by traumatic enemy due to the increase in the permeability of the vascular wall. Traumatic edema can continue from 3 to 5 days. However, during this period, signs of necrosis are determined in the muscles and subcutaneous tissue. The separated from the wound is serous, but by the end of the period, the separated serial-hemorrhagic character, and then purulent.
Fig. four.Radiograph of the facial bones of the skull in the side projection. Knife debris visible in the field of the upper jaw
Fig. five.Radiograph in the side projection of the lower jaw. Firearfish fraction
Fig. 6.Radiograph in the side projection of the upper jaw. Injecting needle is in the maxillary sine
Fig. 7.Radiograph in the lateral projection of the branch of the lower jaw. Foreign body - bullet
Fig. 8.Review radiograph in direct skull projection. Foreign Body - Bullet System "OSA" in the topless sine
Second periodlimited to a period of 3 to 7 days and is characterized inflammatory process. Any wound is infected, and the wounds of the maxillofacial region can be additionally infected through the apparent nasal cavities, oral cavity (penetrating injuries), due to the destroyed teeth. The separated from the wound becomes serous-purulent, then purulent. During this period, purulent "chapels" and the spread of the purulent process in the deep space of the maxillofacial region (the wonderland-maxillary, tidy, the root of the tongue, the ocular, temporal and ompete pits, along the course of the neck of the neck in the mediastum, etc.). By the end of this period with firearms There is a demarcation of tissue damaged at the submolecular level from intact. Already during this period, phenomena characteristic of the next period are noted: the endothelium proliferation occurs in the subcutaneous fatty tissue and in the muscles, new vessels are formed, which is further the basis for the development of granulation tissue. By the end of the period, the purification of the wound begins.
Third periodit lasts 8-10 days and is characterized by the purification of the wound and the development of granulation tissue. At this time, the contraction of the wound begins by forming fibrous tissue from its edges.
The fourth periodit can continue from 11 to 30 days and is characterized by epithelization and scarring. Granulation tissue is transformed into collagen fibers, it becomes all dense. There is a logbook and epithelialization. The epithelium is formed from the edges of the wound and cannot compete at the rate of development of collagen fibers, since the rate of its increase from the edges of the wound around the perimeter is no more than 1 mm in 7-10 days. This is exactly what determines secondary healing Wounds that are always characterized by the presence of a scar.
The course of the wound process of soft tissues of the maxillofacial region differs from the wounds of another localization. By virtue of the anatomophysiological characteristics, wound healing takes place in a shorter time. Good vascularization, innervation, the presence of low-differentiated mesenchymal cells of soft fabrics of the face predetermines a good regenerative ability, reduces the wound healing period and makes it possible to increase the time of the primary surgical processing of the wound to 48 hours.
The duration of periods of the wound process and the severity of flow depend on such factors as:
- the term of assistance and its adequacy on the pre-hospital (replaceable) stage;
- general condition of the patient (age, dehydration, alimentary exhaustion, etc.);
- accompanying diseases (CVD, diabetes, chronic kidney disease, liver, etc.);
- Related damage.
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