Eur J Trauma Emerg Surg (2011) 37:4147 DOI 10.

1007/s00068-010-0023-z

ORIGINAL ARTICLE

Diagnostic and therapeutic aspects in the treatment of gunshot wounds of the viscerocranium
be J. Klatt M. Heiland R. Schmelzle A. Gro P. Pohlenz

Received: 11 September 2009 / Accepted: 26 January 2010 / Published online: 11 May 2010 Urban & Vogel 2010

Abstract Gunshot wounds of the viscerocranium are a rare occurrence during times of peace in Europe. The removal of projectiles is recommended; in some cases, however, this is controversial. The material properties of projectiles and destruction of anatomical landmarks make it difcult to determine their precise location. Therefore, navigation systems and cone-beam computed tomography (CT) provide the surgeon with continuous intraoperative orientation in realtime. The aim of this study was to report our experiences for image-guided removal of projectiles, the use of cone-beam computed tomography and the resulting intra- and postoperative complications. We investigated 50 patients with gunshot wounds of the facial skeleton retrospectively, 32 had imageguided surgical removal of projectiles in the oral and maxillofacial region, 18 had surgical removal of projectiles without navigation assistance and in 28 cases we used cone-beam CT in the case of dislocated projectiles and fractured bones. There was a signicant correlation (p = 0.0136) between the navigated versus not navigated surgery and complication rate (8 vs. 32%, p = 0.0132) including major bleeding, soft tissue infections and nerve damage. Furthermore, we could reduce operating time while using a navigation system and cone-beam CT (p = 0.038). A high tendency between operating time and navigated surgery (p = 0.1103) was found.

In conclusion, there is a signicant correlation between reduced intra- and postoperative complications including wound infections, nerve damage and major bleeding and the appropriate use of a navigation system. In all these cases we were able to present reduced operating time. Cone-beam CT plays a key role as a useful diagnostic tool in detecting projectiles or metallic foreign bodies intraoperatively. Keywords Gunshot wounds Projectiles Imaging techniques Cone-beam computed tomography Navigated surgery

Introduction Gunshot wounds of the maxillofacial region are a rare occurrence during times of peace in Europe. Recently, however, there has been a general increase in number and severity of these injuries [19]. They are mainly caused by suicide attempts, violent conicts or negligent handling [1, 3]. A projectile can contain a variety of materials that show differences in their deformation and fragmentation behavior. Missile characteristics such as ight velocity and rotational velocity, mass, caliber, composition and angle of trajectory all inuence the extent of gunshot injuries [2, 7]. The face comprises a complex anatomical arrangement of bone and soft tissues so that the severity and extent of injury may range from a simple wound of soft tissues to a severe combined destruction of the viscerocranium, including the vascular and nervous systems. Even if the gunshot injury itself does not cause major problems, the surgical removal of projectiles can cause damaging of vital anatomical structures. However, conventional radiography, computed tomography, image-guided surgical removal and

be (&) J. Klatt R. Schmelzle P. Pohlenz A. Gro Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany e-mail: a.groebe@uke.de M. Heiland Department of Oral and Maxillofacial Surgery, General Hospital of Bremerhaven-Reinkenheide, Postbrookstr. 103, 27574 Bremerhaven, Germany e-mail: Max.Heiland@klinikum-bremerhaven.de

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be et al. A. Gro

cone-beam CT have been applied to facilitate that procedure [24, 26]. On the other hand, it has been shown that remaining projectiles may lead to infection [14, 21] or migrate from the site of the entry [18], and it is well known that metal embedded in body tissue can be a source of potential exposure to toxic effects [22, 28]. Moreover, the pellets may dislocate within the soft tissue or sinuses spontaneously. However, it does not seem appropriate to leave a pellet as has been proposed previously and is still discussed with controversy [10, 12]. Even if the exact position is known from imaging data, the accurate reproduction of this position in the physical space of the patient can be difcult, if the projectile or foreign body is not adjacent to a denite anatomical landmark. Therefore, so called navigation systems and cone-beam CT allow the registration of image space and physical space of the patient and give the surgeon continuous real-time orientation intraoperatively. Cone-beam CT is a recently introduced imaging technique that uses a cone-beam moving around a part of the body under examination and allows images to be obtained at lower doses of radiation than conventional CT. The main advantage of cone-beam CT over conventional CT is that the images have considerably fewer metal artefacts and is thus able to localise metallic foreign bodies [18]. The aim of this study was to report our experiences for image-guided removal of projectiles and cone-beam CT in the viscerocranium and whether there is a signicant correlation with resulting intra- and postoperative complications caused by the surgical procedure.

treatment planning often required different or combined radiographic examinations, not only to assess the extent of the hard and soft tissue destruction, but also for location of projectiles and planning the surgical procedure. Statistical analysis For statistical analysis SPSS for Windows (Version 11.5.1) (SPSS Inc., Chicago, IL, USA) was used. Signicance statements refer to p values of two-tailed tests that were less than 0.05.

Results In 23 of the cases we had a retained projectile, followed by a full penetration, a grazing shot or because of shotguns (Fig. 1). The majority of the injuries were caused by violent conicts (n = 19, 38%), negligent handling (n = 11, 22%), suicide attempts (n = 13, 26%) or because of professional reasons (n = 7, 14%). All patients had soft tissue injuries, in 50% of the cases (n = 25) combined with hard-tissue injuries to the viscerocranium (Fig. 2). Following the classication of Gant et al. [9] there were frontal bone fractures, facial injuries, and supraorbital rim fractures in the upper third and soft tissue injuries to the temple. In the middle third of the viscerocranium we had lateral mid-facial fractures (zygomaticoorbital), followed by dentoalveolar fractures and soft tissue injuries to the cheek. These injuries constituted the greatest amount of injuries of the viscerocranium in this study. Finally, the lower third injuries, including the mandible and its related structures, ranged from simple penetrating wounds of the chin to gross destruction with bony defects (Fig. 2). The majority of the sample (n = 44, 88%) had no associated bodily injuries. The most common associated injuries were neurocranium (n = 4, 8%), neck and limb injuries (n = 3, 6%) with the thorax and abdomen (n = 3, 6%) at least common. No special investigations were required in 8% (n = 4) of the sample, conventional x-ray lms alone were

Patients and methods We investigated 50 patients retrospectively. Patient ages ranged from 17 to 77 years with a higher frequency in males (39/78%) than in females (11/22%). Thirty-two had image-guided surgical removal (Brainlab vector vision2) of projectiles in the facial region, 18 had surgical removal of projectiles without navigation assistance. In 28 of the cases we used cone-beam CT (Siemens Arcadis Orbic 3D) intraoperatively to detect spontaneously dislocated projectiles or evaluate the result of treated boney fractures. All patients were being treated at the Department of Oral and Maxillofacial Surgery of the University Medical Center Hamburg-Eppendorf, Germany, between 1998 and 2008. Information and patient data were gained from patient les and patient radiographs (conventional radiographs, conebeam CT and CT scans) retrospectively and were sorted according to the age, gender, type and classication of facial injuries, diagnostic methods, treatment received and complications. Depending on the pattern of injury,

6%

retained projectile, n=23

22% 46%

full penetration, n=13 grazing shot, n=11 shotgun, n=3

26%

Fig. 1 Type of shot causing the injury of the maxillofacial region

Treatment of gunshot wounds of the viscerocranium Fig. 2 Patterns of injury (n = 50)

40% 35% 30% 25% 20% 15% 10% 5% 0%
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Fig. 3 CT scan, showing destruction of the lower jaw after a suicide attempt

requested in 18% (n = 9) and in combination with CT scans and cone-beam CT in 74% (n = 37) of the cases. The conventional radiographs and CT-investigations were done in our Department of Radiology. In case of invisibility of the projectiles on physical examination and inspection, or if the foreign body was close to vital anatomical structures, navigation-assisted surgery was used. In 70.8% of all conventional radiographs and 84.2% of CT scans we found pathologic results preoperatively (Fig. 3). Depending on the material properties of the projectile, a suitable imaging technique should be selected. Metal projectiles are radiopaque and can be detected by all radiological examinations. There are differences between the imaging modalities in the presence of artefacts and nal imaging quality. Since CT and cone-beam CT both produce three-dimensional reconstruction images, the presence of high-density metal objects create artefacts that make it sometimes difcult to obtain accurate information about adjacent anatomical structures. In the case of navigation-assisted surgery, for the registration process image data was transferred to the

navigation system and the foreign bodies were located and marked within the planning software (Fig. 4). Navigation surgery can be performed if either CT or cone-beam CT data sets are available and reference points are identied. Navigation systems have an accuracy of 1 mm [20]. For valid tracking, the relation of the patients rigid body to the patients anatomy has to be established within the registration-process. Intraoperatively a rigid body is afxed to the patients head with bone screws directly to the skull. Afterwards the registration-process was done by identifying the corresponding positions of the titanium markers in the image data as well as on the patient. Navigation facilitates the surgeons orientation to unexposed anatomical structures. It helps to detect the path of the projectile and to preserve surrounding tissues. Cone-beam CT is a modern imaging technique that has the advantage of being associated with a low level of metal artefacts [29]. Despite limitations for soft tissue imaging [8], cone-beam CT is well suited to imaging metal projectiles or to evaluate facial fractures and presents a valuable addition to the wide range of diagnostic tools available.

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44 Fig. 4 Preoperative screenshot from the navigation system showing a triplanar view with the current position of a projectile inside the left orbit

be et al. A. Gro

Fig. 5 Intraoperative imaging system (Siemens Arcadis Orbic 3D) for the detection of a fractured lower jaw (a, b)

All projectiles could be removed via minimally invasive surgical access to the indicated location; revision of the gunshot wounds were performed and the defect-fractured jaw was stabilized with a reconstruction plate (Figs. 5, 6). All surgical procedures were uneventful, patients were given antibiotics prophylactically. The overall complication rate was 34%, there was a signicant correlation (p = 0.0136) between the navigated surgery versus not navigated surgery and complication rate including major bleeding (n = 4 vs. n = 1; 8 vs. 2%), soft tissue infections (n = 7 vs. n = 2; 14 vs. 4%) and nerve damage (n = 3 vs. n = 0; 6 vs. 0%) (Fig. 7, Table 1).

Furthermore there was a signicant correlation (p = 0.038) between the operation time and postoperative complications including mainly wound infections and major bleeding. Another nding was the high tendency between operation time and navigated surgery (p = 0.1103). While using a navigation system we could reduce the operation time. The average duration of a not-navigated surgical procedure was 164 73 min versus 120 76 min for a navigated surgical procedure including reference-process. In 28 of the cases we used a cone-beam CT (Siemens Arcadis Orbic 3D) to reproduce the new position of

Treatment of gunshot wounds of the viscerocranium Fig. 6 Intraoperative situation showing the destruction of soft tissue (a, b), the fractured lower jaw with boney defect (c, d, e), stabilized jaw (f), removed projectile (g) and the situation 6 months after treatment (h)

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spontaneously dislocated projectiles (sinus maxillaris n = 9, temporal region n = 3, orbit n = 3) or evaluate treated bony fractures (n = 13). The foreign bodies were found and removed uneventful in all cases. All patients were hospitalized for at least 6 days, the mean stay was 14.3 days (7.9).

Discussion Gunshot injuries are rare in Western Europe in times of peace. They are usually the result of suicide, violent conicts and

negligent handling. Literature on gunshot wounds to the viscerocranium remains scare. For optimal interdisciplinary management a careful clinical examination, a sound knowledge of gunshot wounds as well as ballistics, and a well planned preoperative examination plan are necessary. Projectiles should be removed surgically whenever possible considering the state of the patient and the location and kind of the foreign body [3, 4]. Gunshot wounds often show damaged tissue, altered anatomy, and projectiles often lie close to vital anatomical structures with difcult surgical access. To identify the exact position of a foreign body and assess the damaged surrounding tissue, a variety

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complications no complications
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% not navigated navigated

be et al. A. Gro Table 1 Intra- and postoperative complications in detail Patient Complication Navigated Pre- and intraoperative D.G. O.M. K.F. K.M. D.H. S.R. P.M. R.O. H.P. P.J. G.S. H.N. Major bleeding (A. facialis) Lesion lingual nerve Lesion facial nerve Lesion inf. alveolar nerve Soft tissue infection (oor of mouth) Soft tissue infection (cheek) Soft tissue infection (cheek) Soft tissue infection (orbit) Soft tissue infection (orbit) Soft tissue infection (orbit) Soft tissue infection (orbit) Major bleeding (A. carotis ext.) Major bleeding (A. carotis comm.) Major bleeding (A. carotis ext.) Major bleeding(A. temporalis) Not navigated

Postoperative

Fig. 7 Complication rate; surgical removal of projectiles with and without appropriate use of a navigation system

of radiological examinations are possible and described in the literature. Since it is usually impossible to identify the exact position of a projectile by visual inspection alone, conventional radiographs, computed tomography (CT scans) and cone-beam CT, which were introduced a few years ago [11, 16, 29], are available. The circumstances that indicated the need of a navigation system were: failure of previous attempts at removal of a projectile or foreign body; the presence of multiple foreign bodies; the presence of structures at risk close to the foreign body or in the path of the surgical access towards the foreign body; and, the objective to achieve minimally invasive surgical access.

W.M. B.M. N.C. H.T. O.S.

Soft tissue infection (cheek) Soft tissue infection(chin)

Sometimes projectiles tend to migrate within the soft tissue from the site of the entry. In these cases navigation based on preoperatively acquired imaging data becomes useless for relocation of a foreign body. To replicate the new position of a projectile within the soft tissue or inside a sinus, cone-beam CT and C-arm systems are available intraoperatively, although there are some limitations for soft tissue imaging [6, 8, 17, 23]. We used cone-beam CT to reproduce the new position of spontaneously dislocated projectiles inside a sinus or to evaluate the immediate outcome of treated bony fractures. In all cases projectiles could be identied and in two cases we reconsidered the position of screws because of the introperative cone-beam CT scan result to avoid any further operation. However, cone-beam CT and C-arm systems are seldom available in oral and maxillofacial operating theaters, alternative techniques like ultrasound guided removal of projectiles as well as a mobile dental X-ray device for the

acquisition of conventional radiographs in two planes with reference markers attached to the surgical site are described in the literature [15, 25]. Although ultrasound is not invasive and does not expose the patient to radiation, it requires direct contact with the surgical eld and increases the risk of contamination. Moreover, the detection of projectiles behind bony structures is not possible. In the case of conventional skull radiographs, the accurate reproduction of a position in soft tissues is difcult, because the projectile is not adjacent to a denite anatomical landmark. Once the position of the projectile has been located and the extent of the damaged tissue has been assessed, an individual treatment plan has to be established. In the literature the removal of projectiles is recommended [4] in some cases, however, in exceptional cases some authors leave a projectile in situ [10, 12]. There are few case reports and not much data about the outcome of those cases, further studies are needed. In more than 50% of the cases we had combined soft tissue and hard tissue injuries. The number of soft tissue injuries alone appears high, considering the intricate anatomy of the maxillofacial region. These ndings were similar to those reported earlier in the literature [9, 13]. Similar to soft tissue repair, the techniques used in immediate reconstruction of bony defects caused by

Treatment of gunshot wounds of the viscerocranium

47 9. Gant TD, Epstein LI. Low-velocity gunshot wounds to the maxillofacial complex. J Trauma. 1979;19(9):6747. 10. Hefner L, Tegetmeyer H, Sterker I, Wiedemann P. Diabolic injury with the localization of foreign bodies in the apex of the intraorbital region. Klin Monatsbl Augenheilkd. 2005;222(11):9237. 11. Heiland M, Schulze D, Adam G, Schmelzle R. 3D-imaging of the facial skeleton with an isocentric mobile C-arm system (Siremobil Iso-C3D). Dentomaxillofac Radiol. 2003;32(1):215. 12. Jenkins RB. When are airgun pellets better left alone? Lancet. 1985;1(8439):12134. 13. Kassan AH, Lalloo R, Kariem G. A retrospective analysis of gunshot injuries to the maxillo-facial region. SADJ. 2000;55(7): 35963. 14. Mahajan M, Shah N. Accidental lodgment of an air gun pellet in the maxillary sinus of a 6-year old girl: a case report. Dent Traumatol. 2004;20(3):17880. 15. Makdissi J. Ultrasound guided removal of an air gun pellet from the temporal fossa: a technical note. Int J Oral Maxillofac Surg. 2004;33(3):3046. 16. Pohlenz P, Blessmann M, Blake F, Heinrich S, et al. Clinical indications and perspectives for intraoperative cone-beam computed tomography in oral and maxillofacial surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(3):4127. 17. Rafferty MA, Siewerdsen JH, Chan Y, Moseley DJ, et al. Investigation of C-arm cone-beam CT-guided surgery of the frontal recess. Laryngoscope. 2005;115(12):213843. 18. Rapp LG, Arce CA, McKenzie R, Darmody WR, et al. Incidence of intracranial bullet fragment migration. Neurol Res. 1999;21(5): 47580. 19. Reiss M, Reiss G, Pilling E. Gunshot injuries in the head-neck areabasic principles, diagnosis and management. Praxis (Bern 1994). 1998;87(24):8328. 20. Schmelzeisen R, Gellrich NC, Schoen R, Gutwald R, et al. Navigation-aided reconstruction of medial orbital wall and oor contour in cranio-maxillofacial reconstruction. Injury. 2004;35(10): 95562. 21. Schultze-Mosgau S, Schmelzeisen R. The pre- and intraoperative localization of supercially situated metallic objects in the head and neck area using a metal detector. Dtsch Zahn Mund Kieferheilkd Zentralbl. 1992;80(2):858. digung und Tod infolge Schuverletzungen. 22. Sellier K (1975) Scha In: TB Mueller (ed) Gerichtliche Medizin. Springer, Berlin, p 563608. 23. Siewerdsen JH, Moseley DJ, Burch S, Bisland SK, et al. Volume CT with a at-panel detector on a mobile, isocentric C-arm: preclinical investigation in guidance of minimally invasive surgery. Med Phys. 2005;32(1):24154. 24. Stein KM, Bahner ML, Merkel J, Ain S, et al. Detection of gunshot residues in routine CTs. Int J Legal Med. 2000;114(12): 158. 25. Stockmann P, Vairaktaris E, Fenner M, Tudor C, et al. Conventional radiographs: are they still the standard in localization of projectiles? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104(4):e715. 26. Stuehmer C, Essig H, Bormann KH, Majdani O, et al. Cone beam CT imaging of airgun injuries to the craniomaxillofacial region. Int J Oral Maxillofac Surg. 2008;37(10):9036. 27. Stuehmer C, Blum KS, Kokemueller H, Tavassol F, et al. Inuence of different types of guns, projectiles, and propellants on patterns of injury to the viscerocranium. J Oral Maxillofac Surg. 2009;67(4):77581. 28. Tolle D. Basal-cell carcinoma of the ethmoid bone following grenade-splinter injury. HNO. 1967;15(5):14750. 29. Zhang Y, Zhang L, Zhu XR, Lee AK, et al. Reducing metal artifacts in cone-beam CT images by preprocessing projection data. Int J Radiat Oncol Biol Phys. 2007;67(3):92432.

gunshot wounds are equally as effective as those employed in reconstruction of routine procedures [5]. The overall complication rate intra- and postoperatively was relatively high and was caused by wound infections, nerve damage and bleeding complications, and have been described before [13, 27]. A possible explanation maybe the large wound surface and extended damage of tissue caused by either the pattern of injury or the operation itself. Our ndings highlight the fact that another reason for these complications is a prolonged operating time, which can be reduced by the assistance of a navigation system. Furthermore the collateral damage of tissue can be reduced by minimally surgical access in case of an appropriate use of a navigation system and cone-beam CT. In conclusion there is a signicant correlation between reduced intra- and postoperative complications including wound infections, nerve damage and major bleeding and the appropriate use of a navigation system and/or conebeam CT. Navigation-assisted surgery facilitates the surgeons orientation to unexposed anatomical structures and projectiles so that we could present in all these cases reduced operation time. Cone-beam CT plays an important role and is a useful diagnostic tool in detecting projectiles or metallic foreign bodies intraoperatively and to evaluate the treatment of fractured bones.
Acknowledgment We acknowledge Dr. Henning Hanken and Associate Professor Marcus Foth for their help and valuable comments on earlier versions of this manuscript. Conict of interest statement None.

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