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ORIGINAL ARTICLE
Diagnostic and therapeutic aspects in the treatment of gunshotwounds of the viscerocranium
A. Grobe • J. Klatt • M. Heiland • R. Schmelzle •
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 difficult to
determine their precise location. Therefore, navigation sys-
tems and cone-beam computed tomography (CT) provide the
surgeon with continuous intraoperative orientation in real-
time. 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 postoper-
ative complications. We investigated 50 patients with gunshot
wounds of the facial skeleton retrospectively, 32 had image-
guided surgical removal of projectiles in the oral and maxil-
lofacial 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 significant 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 oper-
ating time and navigated surgery (p = 0.1103) was found.
In conclusion, there is a significant 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 conflicts or negligent handling
[1, 3].
A projectile can contain a variety of materials that show
differences in their deformation and fragmentation behav-
ior. Missile characteristics such as flight velocity and
rotational velocity, mass, caliber, composition and angle of
trajectory all influence 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
A. Grobe (&) � J. Klatt � R. Schmelzle � P. Pohlenz
Department of Oral and Maxillofacial Surgery,
University Medical Center Hamburg-Eppendorf,
Martinistr. 52, 20246 Hamburg, Germany
e-mail: [email protected]
M. Heiland
Department of Oral and Maxillofacial Surgery,
General Hospital of Bremerhaven-Reinkenheide,
Postbrookstr. 103, 27574 Bremerhaven, Germany
e-mail: [email protected]
Eur J Trauma Emerg Surg (2011) 37:41–47
DOI 10.1007/s00068-010-0023-z
cone-beam CT have been applied to facilitate that proce-
dure [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 spontane-
ously. 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 difficult, if the projectile or
foreign body is not adjacent to a definite 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 contin-
uous real-time orientation intraoperatively.
Cone-beam CT is a recently introduced imaging tech-
nique 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 significant cor-
relation with resulting intra- and postoperative complica-
tions caused by the surgical procedure.
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 pro-
jectiles 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 files
and patient radiographs (conventional radiographs, cone-
beam CT and CT scans) retrospectively and were sorted
according to the age, gender, type and classification of
facial injuries, diagnostic methods, treatment received and
complications. Depending on the pattern of injury,
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. Significance
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 vio-
lent conflicts (n = 19, 38%), negligent handling (n = 11,
22%), suicide attempts (n = 13, 26%) or because of pro-
fessional reasons (n = 7, 14%).
All patients had soft tissue injuries, in 50% of the cases
(n = 25) combined with hard-tissue injuries to the viscer-
ocranium (Fig. 2). Following the classification 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 (zygo-
maticoorbital), 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 films alone were
46%
26%
22%
6%retained projectile, n=23
full penetration, n=13
grazing shot, n=11
shotgun, n=3
Fig. 1 Type of shot causing the injury of the maxillofacial region
42 A. Grobe et al.
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 pro-
jectiles are radiopaque and can be detected by all radio-
logical examinations. There are differences between the
imaging modalities in the presence of artefacts and final
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 difficult 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 identified. 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 affixed 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 surgeon’s 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.
0%
5%
10%
15%
20%
25%
30%
35%
40%
Front
al bo
ne (n
=3)
Orbit (
n=17
)
Zygom
atico
-orb
ital fr
actu
re (n
=6)
Alveolu
s (n=
2)
Tempo
ral fo
ssa
(n=2
)
Cheek
(n=7
)
Ramus
man
dibula
e (n
=3)
Corpu
s man
dibula
e (n
=3)
Ramus
and
Cor
pus m
andib
ulae
(n=4
)
Chin (n
=2)
Lower
lip (n
=1)
Fig. 2 Patterns of injury
(n = 50)
Fig. 3 CT scan, showing
destruction of the lower jaw
after a suicide attempt
Treatment of gunshot wounds of the viscerocranium 43
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
significant 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 significant correlation
(p = 0.038) between the operation time and postoperative
complications including mainly wound infections and
major bleeding.
Another finding was the high tendency between opera-
tion 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
Fig. 4 Preoperative screenshot
from the navigation system
showing a triplanar view with
the current position of a
projectile inside the left orbit
Fig. 5 Intraoperative imaging
system (Siemens Arcadis Orbic
3D) for the detection of a
fractured lower jaw (a, b)
44 A. Grobe et al.
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 conflicts and
negligent handling. Literature on gunshot wounds to the vis-
cerocranium remains scare. For optimal interdisciplinary
management a careful clinical examination, a sound knowl-
edge 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 difficult
surgical access. To identify the exact position of a foreign
body and assess the damaged surrounding tissue, a variety
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)
Treatment of gunshot wounds of the viscerocranium 45
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 naviga-
tion 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.
Sometimes projectiles tend to migrate within the soft tis-
sue 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 frac-
tures. In all cases projectiles could be identified 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 field and increases the risk of con-
tamination. 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 difficult, because the projectile is not adjacent
to a definite 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 lit-
erature 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 anat-
omy of the maxillofacial region. These findings 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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
not navigated navigated
complications
no complications
Fig. 7 Complication rate; surgical removal of projectiles with and
without appropriate use of a navigation system
Table 1 Intra- and postoperative complications in detail
Patient Complication
Navigated Not navigated
Pre- and intraoperative
D.G. – Major bleeding (A. carotis ext.)
O.M. – Major bleeding (A. carotis comm.)
K.F. – Major bleeding (A. carotis ext.)
K.M. – Major bleeding(A. temporalis)
D.H. Major bleeding
(A. facialis)
S.R. – Lesion lingual nerve
P.M. – Lesion facial nerve
R.O. – Lesion inf. alveolar nerve
Postoperative
H.P. – Soft tissue infection (floor of mouth)
P.J. – Soft tissue infection (cheek)
G.S. – Soft tissue infection (cheek)
H.N. – Soft tissue infection (orbit)
W.M. – Soft tissue infection (orbit)
B.M. – Soft tissue infection (orbit)
N.C. – Soft tissue infection (orbit)
H.T. Soft tissue infection
(cheek)
–
O.S. Soft tissue
infection(chin)
–
46 A. Grobe et al.
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 findings 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. Fur-
thermore 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 significant 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 cone-
beam CT. Navigation-assisted surgery facilitates the sur-
geon’s 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 com-
ments on earlier versions of this manuscript.
Conflict of interest statement None.
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Treatment of gunshot wounds of the viscerocranium 47